Provider Demographics
NPI:1124239199
Name:MAD RIVER INTEGRATIVE MEDICINE
Entity type:Organization
Organization Name:MAD RIVER INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WARGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-496-2202
Mailing Address - Street 1:5360 MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673-6003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5360 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673-6003
Practice Address - Country:US
Practice Address - Phone:802-496-2202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN4127Medicare PIN