Provider Demographics
NPI:1164624300
Name:SHELBURNE PEDIATRICS
Entity Type:Organization
Organization Name:SHELBURNE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-985-5099
Mailing Address - Street 1:10 MARSETT RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-6640
Mailing Address - Country:US
Mailing Address - Phone:802-985-5099
Mailing Address - Fax:802-985-2336
Practice Address - Street 1:10 MARSETT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-6640
Practice Address - Country:US
Practice Address - Phone:802-985-5099
Practice Address - Fax:802-985-2336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012925Medicaid