Provider Demographics
NPI:1215017678
Name:STATE OF VERMONT
Entity Type:Organization
Organization Name:STATE OF VERMONT
Other - Org Name:VERMONT STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-241-3100
Mailing Address - Street 1:103 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05671-9800
Mailing Address - Country:US
Mailing Address - Phone:802-241-3009
Mailing Address - Fax:802-241-1439
Practice Address - Street 1:103 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05671-9800
Practice Address - Country:US
Practice Address - Phone:802-241-3009
Practice Address - Fax:802-241-1439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVT4000Medicaid
VT474003Medicaid
VT474002Medicaid
VT4000Medicare ID - Type Unspecified
VTVT4000Medicaid