Provider Demographics
NPI:1750483780
Name:BORDER PEDIATRICS
Entity Type:Organization
Organization Name:BORDER PEDIATRICS
Other - Org Name:BORDER HEALTH CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:BLODGETT
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-873-3009
Mailing Address - Street 1:159 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DERBY LINE
Mailing Address - State:VT
Mailing Address - Zip Code:05830-8754
Mailing Address - Country:US
Mailing Address - Phone:802-873-3009
Mailing Address - Fax:802-873-3176
Practice Address - Street 1:159 MAIN ST
Practice Address - Street 2:
Practice Address - City:DERBY LINE
Practice Address - State:VT
Practice Address - Zip Code:05830-8754
Practice Address - Country:US
Practice Address - Phone:802-873-3009
Practice Address - Fax:802-873-3176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0008363207R00000X
VT042-00083702080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty