Provider Demographics
NPI:1295709350
Name:BELLOMO, STEPHANIE COWAN (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:COWAN
Last Name:BELLOMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1601
Mailing Address - Country:US
Mailing Address - Phone:802-864-6309
Mailing Address - Fax:802-860-4313
Practice Address - Street 1:789 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4933
Practice Address - Country:US
Practice Address - Phone:802-864-0693
Practice Address - Fax:802-860-6613
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006487Medicaid
D03257Medicare UPIN
VTVT648701Medicare PIN