Provider Demographics
NPI:1346459153
Name:VERMONT INTERVENTIONAL SPINE CENTER
Entity Type:Organization
Organization Name:VERMONT INTERVENTIONAL SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERE
Authorized Official - Middle Name:F
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-655-9798
Mailing Address - Street 1:356 MOUNTAIN VIEW DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446
Mailing Address - Country:US
Mailing Address - Phone:802-655-9798
Mailing Address - Fax:802-655-0002
Practice Address - Street 1:356 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5985
Practice Address - Country:US
Practice Address - Phone:802-658-9798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1013828Medicaid
VT1013828Medicaid
VT0002492Medicare PIN