1205941879 NPI number — TWIN RIVER UROLOGY

Table of content: (NPI 1205941879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205941879 NPI number — TWIN RIVER UROLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN RIVER UROLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205941879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 NO MAIN ST
Provider Second Line Business Mailing Address:
TWIN RIVER UROLOGY
Provider Business Mailing Address City Name:
WHITE RIVER JCT
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-296-7370
Provider Business Mailing Address Fax Number:
802-296-7174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 NO MAIN ST
Provider Second Line Business Practice Location Address:
TWIN RIVER UROLOGY
Provider Business Practice Location Address City Name:
WHITE RIVER JCT
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-296-7370
Provider Business Practice Location Address Fax Number:
802-296-7174
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DETZER
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BUS MANAGER
Authorized Official Telephone Number:
802-296-7370

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  0420008456 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208800000X , with the licence number: 8746 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OVN0573 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000301 . This is a "MEDICARE GROUP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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