Provider Demographics
NPI:1457356818
Name:TIMBER LANE ALLERGY & ASTHMA ASSOCIATES, PC
Entity Type:Organization
Organization Name:TIMBER LANE ALLERGY & ASTHMA ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:KENT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:802-864-0294
Mailing Address - Street 1:53 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-5201
Mailing Address - Country:US
Mailing Address - Phone:802-864-0294
Mailing Address - Fax:802-864-3779
Practice Address - Street 1:53 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5201
Practice Address - Country:US
Practice Address - Phone:802-864-0294
Practice Address - Fax:802-864-3779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01398301Medicaid
VT0VN1324Medicaid
TOO2520OtherTRICARE
VT28818OtherBLUE CROSS BLUE SHIELD VT