Provider Demographics
NPI:1518106491
Name:CHAMPLAIN SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:CHAMPLAIN SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:JOHANSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:802-878-1003
Mailing Address - Street 1:67 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3235
Mailing Address - Country:US
Mailing Address - Phone:802-878-1003
Mailing Address - Fax:802-878-9966
Practice Address - Street 1:67 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3235
Practice Address - Country:US
Practice Address - Phone:802-878-1003
Practice Address - Fax:802-878-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
204C00000X
VT0320000304204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty