Healthcare Provider Details

I. General information

NPI: 1730148966
Provider Name (Legal Business Name): MAD RIVER INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 MAIN ST STE. 2
WAITSFIELD VT
05673-6003
US

IV. Provider business mailing address

5360 MAIN ST STE. 2
WAITSFIELD VT
05673-6003
US

V. Phone/Fax

Practice location:
  • Phone: 802-496-2202
  • Fax: 802-496-2223
Mailing address:
  • Phone: 802-496-2202
  • Fax: 802-496-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY J WARGO
Title or Position: PARTNER
Credential: M.D.
Phone: 802-496-2202