Provider Demographics
NPI:1184640377
Name:BOVILL, EDWIN G (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:G
Last Name:BOVILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 CLEARWATER RD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7725
Mailing Address - Country:US
Mailing Address - Phone:802-985-8257
Mailing Address - Fax:802-656-8892
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FLETCHER ALLEN HEALTH CARE, PATHOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-656-0359
Practice Address - Fax:802-656-8892
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006429207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00789859Medicaid
VT00789859Medicaid
VTC65372Medicare UPIN
VTBOVT5076Medicare ID - Type Unspecified