Provider Demographics
NPI:1811961576
Name:BLUMBERG, JILL I (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:I
Last Name:BLUMBERG
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 1:331 OLCOTT DR
Mailing Address - Street 2:SUITE U3
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-9601
Mailing Address - Country:US
Mailing Address - Phone:802-295-6132
Mailing Address - Fax:
Practice Address - Street 1:331 OLCOTT DR
Practice Address - Street 2:SUITE U3
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-9601
Practice Address - Country:US
Practice Address - Phone:802-295-6132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420012818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30203299Medicaid
VT1009068Medicaid
NHRE694702Medicare PIN
NH30203299Medicaid
NHRE694703Medicare PIN