1568710028 NPI number — UPPER VALLEY PATHOLOGY, PLLC

Table of content: (NPI 1568710028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568710028 NPI number — UPPER VALLEY PATHOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPPER VALLEY PATHOLOGY, PLLC
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:
1568710028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 84
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWICH
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05055-0084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-734-8052
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32 ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWICH
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05055-9446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-649-7229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
802-734-8052

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  14842 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X , with the licence number: 042-0011960 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1021236 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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