=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336249077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS FERRENTINO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2006
-----------------------------------------------------
Last Update Date | 10/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 COLCHESTER AVE FAHC, MCHV CAMPUS, ACC 5TH FLOOR
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-847-2554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 COLCHESTER AVE MCHV CAMPUS, SMITH 251
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-847-2554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 0420009319
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------