Healthcare Provider Details

I. General information

NPI: 1104925817
Provider Name (Legal Business Name): ESSEX PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/09/2023
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 MAIN ST
ESSEX JCT VT
05452-3207
US

IV. Provider business mailing address

89 MAIN ST
ESSEX JCT VT
05452-3207
US

V. Phone/Fax

Practice location:
  • Phone: 802-879-6556
  • Fax: 802-872-8021
Mailing address:
  • Phone: 802-879-6556
  • Fax: 802-872-8021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number120475
License Number StateVT

VIII. Authorized Official

Name: MS. SUE ROGERS-LOW
Title or Position: OFFICE MANAGER
Credential:
Phone: 802-879-6556