=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962558502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VERMONT PAIN MANAGEMENT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 03/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 KENNEDY DR STE U1
-----------------------------------------------------
City | SOUTH BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05403-7166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-861-6100
-----------------------------------------------------
Fax | 802-861-6101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 KENNEDY DR STE U1
-----------------------------------------------------
City | SOUTH BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05403-7166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-861-6100
-----------------------------------------------------
Fax | 802-861-6101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EVAN MUSMAN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 802-861-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 032-0000427
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------