=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336163419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS ALAN GENTILE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 07/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 COLCHESTER AVE FAHC, EMERGENCY DEPARTMENT
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-847-3982
-----------------------------------------------------
Fax | 802-847-5963
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 467 BEAVER CREEK ROAD
-----------------------------------------------------
City | SHELBURNE
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 42-0009006
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------