1770674137 NPI number — DR. HENRY SOUTHALL M.D.

Table of content: DR. HENRY SOUTHALL M.D. (NPI 1770674137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770674137 NPI number — DR. HENRY SOUTHALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHALL
Provider First Name:
HENRY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1770674137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISVILLE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05661-0250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-888-5000
Provider Business Mailing Address Fax Number:
802-888-5060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
439 WASHINGTON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORRISVILLE
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05661-8969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-888-5000
Provider Business Practice Location Address Fax Number:
802-888-5060
Provider Enumeration Date:
09/28/2006

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: 207RC0000X , with the licence number:  042-0005150 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 042-0005150 , 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: 0004503 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11V054 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 31V500 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 4503 . This is a "BC/BS OF VT" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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