Provider Demographics
NPI:1164418455
Name:LAKE CHAMPLAIN GYNECOLOGIC ONCOLOGY, PC
Entity Type:Organization
Organization Name:LAKE CHAMPLAIN GYNECOLOGIC ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAMAL
Authorized Official - Middle Name:H
Authorized Official - Last Name:ELTABBAKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-859-9500
Mailing Address - Street 1:1060 HINESBURG RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7612
Mailing Address - Country:US
Mailing Address - Phone:802-859-9500
Mailing Address - Fax:802-859-9944
Practice Address - Street 1:1060 HINESBURG RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7612
Practice Address - Country:US
Practice Address - Phone:802-859-9500
Practice Address - Fax:802-859-9944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01760585Medicaid
VT1008935Medicaid
NY01760585Medicaid
VTVN2936Medicare PIN