1861569204 NPI number — CHRISTOPHER JAMES GRACE MD

Table of content: CHRISTOPHER JAMES GRACE MD (NPI 1861569204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861569204 NPI number — CHRISTOPHER JAMES GRACE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRACE
Provider First Name:
CHRISTOPHER
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1861569204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 COLCHESTER AVENUE
Provider Second Line Business Mailing Address:
FLETCHER ALLEN HEALTH CARE SMITH 275
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-847-2264
Provider Business Mailing Address Fax Number:
802-847-5322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLCHESTER AVENUE
Provider Second Line Business Practice Location Address:
FLETCHER ALLEN HEALTH EAST PAVILLION 5TH FLOOR
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-847-4594
Provider Business Practice Location Address Fax Number:
802-847-9783
Provider Enumeration Date:
11/29/2006

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: 207RI0200X , with the licence number:  0420007568 , 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: 1034660 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0009082 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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