1003985821 NPI number — DTGC, PC

Table of content: (NPI 1003985821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003985821 NPI number — DTGC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DTGC, PC
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:
VERMONT DERMATOPATHOLOGY
Provider Other Organization Name Type Code:
3
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:
1003985821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 FARRELL ST
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
SOUTH BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05403-6112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-658-6269
Provider Business Mailing Address Fax Number:
802-860-4642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 FARRELL ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SOUTH BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05403-6112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-658-6269
Provider Business Practice Location Address Fax Number:
802-860-4642
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANTLEY
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
MURER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
802-658-6269

Provider Taxonomy Codes

  • Taxonomy code: 207ZD0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: OVN2726 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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