Provider Demographics
NPI:1205821220
Name:BRACK, VIRGINIA C (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:C
Last Name:BRACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CLIFF ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055-9412
Mailing Address - Country:US
Mailing Address - Phone:802-649-3891
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010058208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0RE6014Medicaid
F33061Medicare UPIN
VT0RE6014Medicaid