Healthcare Provider Details

I. General information

NPI: 1164538591
Provider Name (Legal Business Name): ROBERT C KIESS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S MAIN ST
RANDOLPH VT
05060-1381
US

IV. Provider business mailing address

PO BOX 2000
RANDOLPH VT
05060-2000
US

V. Phone/Fax

Practice location:
  • Phone: 802-763-8000
  • Fax: 802-728-2394
Mailing address:
  • Phone: 802-763-8000
  • Fax: 802-728-2394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0420010930
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: