=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770674137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY SOUTHALL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 439 WASHINGTON HWY
-----------------------------------------------------
City | MORRISVILLE
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05661-8969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-888-5000
-----------------------------------------------------
Fax | 802-888-5060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 250
-----------------------------------------------------
City | MORRISVILLE
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05661-0250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-888-5000
-----------------------------------------------------
Fax | 802-888-5060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 042-0005150
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 042-0005150
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------