Provider Demographics
NPI:1427255538
Name:GREEN MOUNTAIN NEUROLOGY, INC
Entity type:Organization
Organization Name:GREEN MOUNTAIN NEUROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:S
Authorized Official - Last Name:KLOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-395-7517
Mailing Address - Street 1:777 NORTH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4147
Mailing Address - Country:US
Mailing Address - Phone:413-395-7517
Mailing Address - Fax:413-395-7518
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4147
Practice Address - Country:US
Practice Address - Phone:413-395-7517
Practice Address - Fax:413-395-7518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA719162084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA22838OtherBMC HEALTH NET
MA9730541Medicaid
MA990894OtherMVP IND #
MA18776OtherHNE
MAM17766OtherMASS BCBS GRP #
MAE97163Medicare UPIN
MAE97163Medicare UPIN