1679095475 NPI number — TY MACWALTERS CPHT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679095475 NPI number — TY MACWALTERS CPHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACWALTERS
Provider First Name:
TY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPHT
Provider Gender Code:
M

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:
1679095475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 547
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARRE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05641-0547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-371-4169
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 FISHER ROAD
Provider Second Line Business Practice Location Address:
CENTRAL VERMONT MEDICAL CENTER
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05602-0560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-371-4857
Provider Business Practice Location Address Fax Number:
802-371-4408
Provider Enumeration Date:
07/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X , with the licence number:  037.0001187 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 121.0000650 . This is a "STATE LICENSE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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