Provider Demographics
NPI:1316085814
Name:MID VERMONT PATHOLOGY PC
Entity type:Organization
Organization Name:MID VERMONT PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MASUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-259-3490
Mailing Address - Street 1:160 ALLEN STREET
Mailing Address - Street 2:RUTLAND REGIONAL MEDICAL CENTER
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-747-1786
Mailing Address - Fax:802-747-6525
Practice Address - Street 1:160 ALLEN STREET
Practice Address - Street 2:RUTLAND REGIONAL MEDICAL CENTER
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-747-1786
Practice Address - Fax:802-747-6525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2068Medicaid
VTOVN2068Medicaid