Provider Demographics
NPI:1205640604
Name:GREEN MOUNTAIN INFECTIOUS DISEASE LLC
Entity type:Organization
Organization Name:GREEN MOUNTAIN INFECTIOUS DISEASE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INFECTIOUS DISEASE CONSULTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GAVIN
Authorized Official - Last Name:COTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-807-4452
Mailing Address - Street 1:69 ALLEN ST STE 8
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4564
Mailing Address - Country:US
Mailing Address - Phone:207-807-4452
Mailing Address - Fax:
Practice Address - Street 1:69 ALLEN ST STE 8
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4564
Practice Address - Country:US
Practice Address - Phone:207-807-4452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty