Provider Demographics
NPI:1669578902
Name:EGBERT, CHARLES CORNELIUS (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CORNELIUS
Last Name:EGBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 ALLEN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-775-7798
Mailing Address - Fax:802-775-7762
Practice Address - Street 1:71 ALLEN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-7798
Practice Address - Fax:802-775-7762
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420008781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT48181OtherBCBS
VTOVN2913Medicaid
H01241Medicare UPIN
VN2073Medicare ID - Type Unspecified