Provider Demographics
NPI:1194701623
Name:GREEN MOUNTAIN FAMILY PRACTICE
Entity type:Organization
Organization Name:GREEN MOUNTAIN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:DEMMING
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-485-4161
Mailing Address - Street 1:63 CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05663-5704
Mailing Address - Country:US
Mailing Address - Phone:802-485-4161
Mailing Address - Fax:802-485-4163
Practice Address - Street 1:63 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05663-5704
Practice Address - Country:US
Practice Address - Phone:802-485-4161
Practice Address - Fax:802-485-4163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005666Medicaid
VT0005666Medicaid