Healthcare Provider Details

I. General information

NPI: 1770682106
Provider Name (Legal Business Name): MIRIAM BLODGETT TATUM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 MAIN STREET
DERBY LINE VT
05830
US

IV. Provider business mailing address

PO BOX 970 159 MAIN STREET
DERBY LINE VT
05830-0970
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number042-0008370
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: