Healthcare Provider Details

I. General information

NPI: 1114180494
Provider Name (Legal Business Name): KEITH MICHL MD FACP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7252 MAIN STREET
MANCHESTER CTR VT
05255
US

IV. Provider business mailing address

7252 MAIN STREET PO BOX 1431
MANCHESTER CENTER VT
05255
US

V. Phone/Fax

Practice location:
  • Phone: 802-362-9031
  • Fax: 802-362-7562
Mailing address:
  • Phone: 802-362-9031
  • Fax: 802-362-7562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0420007111
License Number StateVT

VIII. Authorized Official

Name: DR. KEITH W MICHL
Title or Position: INTERNAL MEDICINE
Credential: MD
Phone: 802-362-9031