Provider Demographics
NPI:1689705139
Name:GREEN MOUNTAIN REHABILITATION & SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:GREEN MOUNTAIN REHABILITATION & SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ELSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:802-861-6700
Mailing Address - Street 1:90 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-8419
Mailing Address - Country:US
Mailing Address - Phone:802-861-6700
Mailing Address - Fax:802-861-2143
Practice Address - Street 1:90 MAIN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8419
Practice Address - Country:US
Practice Address - Phone:802-861-6700
Practice Address - Fax:802-861-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-00032482251X0800X
VT040-00034012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT4149377OtherMVP
VT1386659100OtherNPI
VT5268301OtherFAP
VT6000628OtherMVP
VT9554226OtherCIGNA
VT00049991OtherBCBS
VT1007705Medicaid
VT48616OtherTVHP
VT5273607OtherFAP
VT00048616OtherBCBS
VT1009289Medicaid
VT1992711923OtherNPI
VT6245674OtherCIGNA
VT69511OtherTVHP
VT5273607OtherFAP
VT1007705Medicaid