Provider Demographics
NPI:1659597698
Name:CHARLES VERMONT, M.D., PLLC
Entity Type:Organization
Organization Name:CHARLES VERMONT, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:VERMONT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-887-2669
Mailing Address - Street 1:1480 WEST FIRST NORTH
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857
Mailing Address - Country:US
Mailing Address - Phone:870-887-2669
Mailing Address - Fax:870-887-5373
Practice Address - Street 1:1480 WEST FIRST NORTH
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857
Practice Address - Country:US
Practice Address - Phone:870-887-2669
Practice Address - Fax:870-887-5373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7159207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11757002Medicaid
50963Medicare ID - Type Unspecified
AR11757002Medicaid