Provider Demographics
NPI:1912025552
Name:ORLEANS MEDICAL CLINIC
Entity Type:Organization
Organization Name:ORLEANS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-754-2220
Mailing Address - Street 1:30 EAST ST
Mailing Address - Street 2:
Mailing Address - City:ORLEANS
Mailing Address - State:VT
Mailing Address - Zip Code:05860-1230
Mailing Address - Country:US
Mailing Address - Phone:802-754-2220
Mailing Address - Fax:802-754-2195
Practice Address - Street 1:30 EAST ST
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:VT
Practice Address - Zip Code:05860-1230
Practice Address - Country:US
Practice Address - Phone:802-754-2220
Practice Address - Fax:802-754-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2319Medicaid
VT00019768OtherVT BCBS
VT00019768OtherVT BCBS