Provider Demographics
NPI:1649746082
Name:CHAMPLAIN ANESTHESIA, PLC
Entity Type:Organization
Organization Name:CHAMPLAIN ANESTHESIA, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-318-5396
Mailing Address - Street 1:PO BOX 4617
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05406-4617
Mailing Address - Country:US
Mailing Address - Phone:802-318-5396
Mailing Address - Fax:
Practice Address - Street 1:593 HERCULES DRIVE
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5993
Practice Address - Country:US
Practice Address - Phone:802-488-5350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN1301Medicaid