Provider Demographics
NPI:1568578656
Name:BROOKSIDE PEDIATRICS & ADOLESCENT MEDICINE PLLC
Entity Type:Organization
Organization Name:BROOKSIDE PEDIATRICS & ADOLESCENT MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-442-2264
Mailing Address - Street 1:194 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201
Mailing Address - Country:US
Mailing Address - Phone:802-442-2264
Mailing Address - Fax:802-442-2337
Practice Address - Street 1:194 NORTH STREET
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201
Practice Address - Country:US
Practice Address - Phone:802-442-2264
Practice Address - Fax:802-442-2337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007123Medicaid