Provider Demographics
NPI:1518032564
Name:WHITE RIVER FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:WHITE RIVER FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:NUNLIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-295-6132
Mailing Address - Street 1:331 OLCOTT DRIVE
Mailing Address - Street 2:SUITE U3
Mailing Address - City:WHITE RIVER JCT
Mailing Address - State:VT
Mailing Address - Zip Code:05001
Mailing Address - Country:US
Mailing Address - Phone:802-295-6132
Mailing Address - Fax:802-295-1358
Practice Address - Street 1:331 OLCOTT DRIVE
Practice Address - Street 2:SUITE U3
Practice Address - City:WHITE RIVER JCT
Practice Address - State:VT
Practice Address - Zip Code:05001
Practice Address - Country:US
Practice Address - Phone:802-295-6132
Practice Address - Fax:802-295-1358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011112Medicaid
VT1011112Medicaid
VN3604Medicare ID - Type Unspecified