Healthcare Provider Details

I. General information

NPI: 1154508638
Provider Name (Legal Business Name): RYAN RUSSELL MCCOOL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2008
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 COUNTY RD
WINDSOR VT
05089-9000
US

IV. Provider business mailing address

289 COUNTY RD
WINDSOR VT
05089-9000
US

V. Phone/Fax

Practice location:
  • Phone: 802-674-7300
  • Fax: 802-674-7314
Mailing address:
  • Phone: 802-674-7300
  • Fax: 802-674-7314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number6825185-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0420012186
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: