Provider Demographics
NPI:1730103300
Name:VERMONT SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:VERMONT SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:COREY
Authorized Official - Last Name:GIBEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-775-1300
Mailing Address - Street 1:5 ALBERT CREE DR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-775-1300
Mailing Address - Fax:802-773-9300
Practice Address - Street 1:5 ALBERT CREE DR
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-1300
Practice Address - Fax:802-773-9300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4471OtherBLUE CROSS OF VT
VTOVN2225Medicaid
9690007OtherCIGNA
50922OtherMVP
50922OtherMVP
VTOVN2225Medicaid