Healthcare Provider Details

I. General information

NPI: 1245563584
Provider Name (Legal Business Name): MT MANSFIELD OBSTETRICS AND GYNECOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 09/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 WILLISTON RD SUITE 220
SOUTH BURLINGTON VT
05403-6491
US

IV. Provider business mailing address

74 FOOTHILLS DR
JERICHO VT
05465-2081
US

V. Phone/Fax

Practice location:
  • Phone: 802-861-0200
  • Fax:
Mailing address:
  • Phone: 802-899-2984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number042-00007744
License Number StateVT

VIII. Authorized Official

Name: DR. GEORGE WILLIAM TILL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 802-899-2984