Healthcare Provider Details

I. General information

NPI: 1750483780
Provider Name (Legal Business Name): BORDER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 MAIN ST
DERBY LINE VT
05830-8754
US

IV. Provider business mailing address

159 MAIN ST
DERBY LINE VT
05830-8754
US

V. Phone/Fax

Practice location:
  • Phone: 802-873-3009
  • Fax: 802-873-3176
Mailing address:
  • Phone: 802-873-3009
  • Fax: 802-873-3176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042-0008363
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number042-0008370
License Number StateVT

VIII. Authorized Official

Name: DR. MIRIAM BLODGETT TATUM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 802-873-3009