Provider Demographics
NPI:1518059039
Name:GREEN MOUNTAIN RADIOLOGY
Entity Type:Organization
Organization Name:GREEN MOUNTAIN RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-371-4249
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MORETOWN
Mailing Address - State:VT
Mailing Address - Zip Code:05660-0660
Mailing Address - Country:US
Mailing Address - Phone:802-496-5252
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:CENTRAL VERMONT HOSPITAL
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005061Medicaid
VTGREE00005061OtherBLUE SHIELD
VTVT5061Medicare ID - Type Unspecified