Provider Demographics
NPI:1598704157
Name:GREEN MOUNTAIN GENERAL SURGERY PC
Entity Type:Organization
Organization Name:GREEN MOUNTAIN GENERAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-888-2311
Mailing Address - Street 1:530 WASHINGTON HIGHWAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661
Mailing Address - Country:US
Mailing Address - Phone:802-888-2311
Mailing Address - Fax:802-888-0031
Practice Address - Street 1:530 WASHINGTON HIGHWAY
Practice Address - Street 2:HEALTH CENTER BUILDING SUITE 3
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661
Practice Address - Country:US
Practice Address - Phone:802-888-2311
Practice Address - Fax:802-888-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTGREE00059225OtherBLUE CROSS BLUE SHIELD
VT1009478Medicaid
DA5793OtherRAILROAD MEDICARE
0VN3088Medicare ID - Type Unspecified