Provider Demographics
NPI:1760401673
Name:SHULL, SUSAN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:SHULL
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-0850
Mailing Address - Country:US
Mailing Address - Phone:802-985-2585
Mailing Address - Fax:802-985-5092
Practice Address - Street 1:5138 SHELBURNE RD
Practice Address - Street 2:SUITE 12
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-6698
Practice Address - Country:US
Practice Address - Phone:802-985-2585
Practice Address - Fax:802-985-5092
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002349Medicaid
VT0002349Medicare ID - Type Unspecified
VT0002349Medicaid