Provider Demographics
NPI:1669408456
Name:ERISMAN, SUSAN P (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:ERISMAN
Suffix:
Gender:F
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:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-0083
Mailing Address - Country:US
Mailing Address - Phone:802-748-9501
Mailing Address - Fax:
Practice Address - Street 1:NVRH CORNER MEDICAL
Practice Address - Street 2:195 INDUSTRIAL PKWY
Practice Address - City:LYNDON
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0008496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0316Medicaid
VTOVN0316Medicaid
VTE31018Medicare UPIN