Provider Demographics
NPI:1114086808
Name:MAD RIVER INTEGRATIVE MEDICINE
Entity Type:Organization
Organization Name:MAD RIVER INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WARGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-496-2202
Mailing Address - Street 1:5360 MAIN ST
Mailing Address - Street 2:STE 2
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673-6003
Mailing Address - Country:US
Mailing Address - Phone:802-496-2202
Mailing Address - Fax:802-496-2223
Practice Address - Street 1:5360 MAIN ST
Practice Address - Street 2:STE 2
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673-6003
Practice Address - Country:US
Practice Address - Phone:802-496-2202
Practice Address - Fax:802-496-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007289261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN4127Medicare PIN