Provider Demographics
NPI:1891709622
Name:VERMONT PHYSICIANS CLINIC
Entity Type:Organization
Organization Name:VERMONT PHYSICIANS CLINIC
Other - Org Name:GREEN MOUNTAIN CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBERTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-773-1128
Mailing Address - Street 1:6 COMMONS ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4651
Mailing Address - Country:US
Mailing Address - Phone:802-773-1128
Mailing Address - Fax:802-773-8501
Practice Address - Street 1:6 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4651
Practice Address - Country:US
Practice Address - Phone:802-773-1128
Practice Address - Fax:802-773-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN2263Medicaid
VT49292OtherBCBS
VT49292OtherBCBS