Healthcare Provider Details

I. General information

NPI: 1649746082
Provider Name (Legal Business Name): CHAMPLAIN ANESTHESIA, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 HERCULES DRIVE
COLCHESTER VT
05446-5993
US

IV. Provider business mailing address

PO BOX 4617
BURLINGTON VT
05406-4617
US

V. Phone/Fax

Practice location:
  • Phone: 802-488-5350
  • Fax:
Mailing address:
  • Phone: 802-318-5396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN BRADLEY MASON
Title or Position: PRESIDENT
Credential: MD
Phone: 802-318-5396