Provider Demographics
NPI:1942311949
Name:NEUROLOGICAL DIAGNOSTIC AND TREATMENT CENTER INC
Entity Type:Organization
Organization Name:NEUROLOGICAL DIAGNOSTIC AND TREATMENT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-447-7577
Mailing Address - Street 1:160 BENMONT AVE
Mailing Address - Street 2:SUITE 25
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1873
Mailing Address - Country:US
Mailing Address - Phone:802-447-7577
Mailing Address - Fax:802-447-2676
Practice Address - Street 1:276 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6835
Practice Address - Country:US
Practice Address - Phone:413-499-5888
Practice Address - Fax:413-499-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9730265Medicaid
MA9730265Medicaid