Provider Demographics
NPI:1245563584
Name:MT MANSFIELD OBSTETRICS AND GYNECOLOGY
Entity Type:Organization
Organization Name:MT MANSFIELD OBSTETRICS AND GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:TILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-899-2984
Mailing Address - Street 1:74 FOOTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-2081
Mailing Address - Country:US
Mailing Address - Phone:802-899-2984
Mailing Address - Fax:
Practice Address - Street 1:1775 WILLISTON RD
Practice Address - Street 2:SUITE 220
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6491
Practice Address - Country:US
Practice Address - Phone:802-861-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00007744207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty