Provider Demographics
NPI:1750596110
Name:BENNINGTON COLLEGE HEALTH SERVICES
Entity type:Organization
Organization Name:BENNINGTON COLLEGE HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANSELMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-440-4426
Mailing Address - Street 1:1 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-0006
Mailing Address - Country:US
Mailing Address - Phone:802-440-4426
Mailing Address - Fax:802-440-4427
Practice Address - Street 1:1 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-0006
Practice Address - Country:US
Practice Address - Phone:802-440-4426
Practice Address - Fax:802-440-4427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0260009599163W00000X
VT0260008617163W00000X
VT0260029265163W00000X
VT0420010651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CVT405COtherBOLLINGER INC
VTBENN00005278OtherBLUE CROSS BLUE SHIELD
G65837Medicare UPIN