Provider Demographics
NPI:1326212804
Name:MARY A. STANLEY, MD PC
Entity Type:Organization
Organization Name:MARY A. STANLEY, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-878-4410
Mailing Address - Street 1:71 KNIGHT LN
Mailing Address - Street 2:STE 20
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4432
Mailing Address - Country:US
Mailing Address - Phone:802-878-4410
Mailing Address - Fax:802-872-9088
Practice Address - Street 1:71 KNIGHT LN
Practice Address - Street 2:STE 20
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4432
Practice Address - Country:US
Practice Address - Phone:802-878-4410
Practice Address - Fax:802-872-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015005Medicaid
VT1015005Medicaid