Healthcare Provider Details

I. General information

NPI: 1730160532
Provider Name (Legal Business Name): GREEN MOUNTAIN UROLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 COLLEGE PKWY SUITE302
COLCHESTER VT
05446-3052
US

IV. Provider business mailing address

792 COLLEGE PKWY SUITE302
COLCHESTER VT
05446-3052
US

V. Phone/Fax

Practice location:
  • Phone: 802-655-4900
  • Fax: 802-655-5017
Mailing address:
  • Phone: 802-655-4900
  • Fax: 802-655-5017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: RICHARD T GRUNERT
Title or Position: PRESIDENT
Credential: MD
Phone: 802-655-4900