Provider Demographics
NPI:1093027443
Name:IP, HERBERT S M (MD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:S M
Last Name:IP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:289 COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-9000
Mailing Address - Country:US
Mailing Address - Phone:802-674-6711
Mailing Address - Fax:802-674-7349
Practice Address - Street 1:289 COUNTY RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-9000
Practice Address - Country:US
Practice Address - Phone:802-674-6711
Practice Address - Fax:802-674-7349
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0012863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1023413Medicaid
VT1023413Medicaid