Provider Demographics
NPI:1114175627
Name:VERNON INTEGRATIVE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:VERNON INTEGRATIVE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD INTERNAL MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:TRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-754-9950
Mailing Address - Street 1:10 WINTHROP ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604
Mailing Address - Country:US
Mailing Address - Phone:508-754-9950
Mailing Address - Fax:508-754-2592
Practice Address - Street 1:10 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604
Practice Address - Country:US
Practice Address - Phone:508-754-9950
Practice Address - Fax:508-754-2592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80587207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0400664OtherEVERCARE
MA43899OtherBMCHP
MA5841132OtherAETNA
1928586OtherCIGNA
33586OtherHEALTH NEW ENGLAND
MA110082379AMedicaid
29736OtherFALLON
MA6141990001OtherNATIONAL SUPPLIER CLEARINGHOUSE
J16290OtherBLUE CROSS BLUE SHIELD
0400053OtherUNITED HEALTH CARE
985162OtherNETWORK HEALTH
MA3144941Medicaid
080587OtherTUFTS
66212OtherHARVARD PILGRIM
66212OtherHARVARD PILGRIM
MA6141990001OtherNATIONAL SUPPLIER CLEARINGHOUSE
MA5841132OtherAETNA