=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427458124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEASTERN REPRODUCTIVE MEDICINE LABORATORIES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2014
-----------------------------------------------------
Last Update Date | 03/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 WESTVIEW RD SUITE 302
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05446-8025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-655-8888
-----------------------------------------------------
Fax | 802-985-2566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 WESTVIEW RD SUITE 302
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05446-8025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-655-8888
-----------------------------------------------------
Fax | 802-985-2566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED REP/OWNER
-----------------------------------------------------
Name | PETER R. CASSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 802-655-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 47D2079212
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------