Healthcare Provider Details

I. General information

NPI: 1285674994
Provider Name (Legal Business Name): MOUNTAIN SPORTS MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 GRAND SUMMIT WAY
WEST DOVER VT
05356
US

IV. Provider business mailing address

PO BOX 207
WEST DOVER VT
05356-0207
US

V. Phone/Fax

Practice location:
  • Phone: 802-464-9300
  • Fax: 802-464-9314
Mailing address:
  • Phone: 802-464-9300
  • Fax: 802-464-9314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. CHERYL L. ROTHMAN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 802-464-9311