Healthcare Provider Details

I. General information

NPI: 1508897786
Provider Name (Legal Business Name): JERRY M LINSEISEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 WASHINGTON HWY
MORRISVILLE VT
05661-8973
US

IV. Provider business mailing address

528 WASHINGTON HWY
MORRISVILLE VT
05661-8973
US

V. Phone/Fax

Practice location:
  • Phone: 802-888-4231
  • Fax: 802-888-8203
Mailing address:
  • Phone: 802-888-4231
  • Fax: 802-888-8203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberEC131111
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number050012345
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0420013437
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: