1750483780 NPI number — BORDER PEDIATRICS

Table of content: (NPI 1750483780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750483780 NPI number — BORDER PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BORDER PEDIATRICS
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:
BORDER HEALTH CENTER
Provider Other Organization Name Type Code:
4
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:
1750483780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
159 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DERBY LINE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05830-8754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-873-3009
Provider Business Mailing Address Fax Number:
802-873-3176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERBY LINE
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05830-8754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-873-3009
Provider Business Practice Location Address Fax Number:
802-873-3176
Provider Enumeration Date:
09/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TATUM
Authorized Official First Name:
MIRIAM
Authorized Official Middle Name:
BLODGETT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
802-873-3009

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  042-0008363 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080A0000X , with the licence number: 042-0008370 , 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)