Provider Demographics
NPI:1700835741
Name:BENNINGTON FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:BENNINGTON FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLINGSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:802-447-1191
Mailing Address - Street 1:339 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2253
Mailing Address - Country:US
Mailing Address - Phone:802-447-1191
Mailing Address - Fax:802-442-6614
Practice Address - Street 1:339 DEWEY ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2253
Practice Address - Country:US
Practice Address - Phone:802-447-1191
Practice Address - Fax:802-442-6614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT8000038Medicaid
VT701100449Medicaid
VT701100449Medicaid