Provider Demographics
NPI:1871690099
Name:MAPLE TREE GENERAL SURGERY
Entity Type:Organization
Organization Name:MAPLE TREE GENERAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JIMMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-775-7745
Mailing Address - Street 1:215 STRATTON RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4621
Mailing Address - Country:US
Mailing Address - Phone:802-775-7745
Mailing Address - Fax:802-775-5155
Practice Address - Street 1:215 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-775-7745
Practice Address - Fax:802-775-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010388208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN3695Medicare ID - Type Unspecified