Provider Demographics
NPI:1265692453
Name:BEVERLY J. ROSEBERRY, MD, PC
Entity type:Organization
Organization Name:BEVERLY J. ROSEBERRY, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ROSEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-779-0114
Mailing Address - Street 1:11 COMMONS ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4652
Mailing Address - Country:US
Mailing Address - Phone:802-779-0114
Mailing Address - Fax:802-779-0123
Practice Address - Street 1:11 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4652
Practice Address - Country:US
Practice Address - Phone:802-779-0114
Practice Address - Fax:802-779-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0011545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0012204Medicare PIN