Healthcare Provider Details

I. General information

NPI: 1194701623
Provider Name (Legal Business Name): GREEN MOUNTAIN FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CRESCENT AVE
NORTHFIELD VT
05663-5704
US

IV. Provider business mailing address

63 CRESCENT AVE
NORTHFIELD VT
05663-5704
US

V. Phone/Fax

Practice location:
  • Phone: 802-485-4161
  • Fax: 802-485-4163
Mailing address:
  • Phone: 802-485-4161
  • Fax: 802-485-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRAIG DEMMING SULLIVAN
Title or Position: PARTNER
Credential:
Phone: 802-485-4161