Healthcare Provider Details

I. General information

NPI: 1366995193
Provider Name (Legal Business Name): IRISH SPRINGS INTERNAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 OLD MAIN STREET
JEFFERSONVILLE VT
05464-0157
US

IV. Provider business mailing address

22 OLD MAIN STREET PO BOX 157
JEFFERSONVILLE VT
05464-0157
US

V. Phone/Fax

Practice location:
  • Phone: 802-644-1432
  • Fax: 802-644-1454
Mailing address:
  • Phone: 802-644-1432
  • Fax: 802-644-1454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateVT

VIII. Authorized Official

Name: JOHN M DUNN
Title or Position: AUTHORIZED REP/OWNER
Credential: MD
Phone: 802-644-1432