Provider Demographics
NPI:1396857728
Name:MIDDLEBURY RADIOLOGISTS, PLLC
Entity Type:Organization
Organization Name:MIDDLEBURY RADIOLOGISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-388-8851
Mailing Address - Street 1:1119 BASIN HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:BRIDPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05734-9570
Mailing Address - Country:US
Mailing Address - Phone:802-388-8851
Mailing Address - Fax:802-388-8821
Practice Address - Street 1:115 PORTER DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-8423
Practice Address - Country:US
Practice Address - Phone:802-388-8851
Practice Address - Fax:802-388-8821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT29573OtherBLUE CROSS BLUE SHIELD
VT0VN1598Medicaid
VT29573OtherBLUE CROSS BLUE SHIELD