Provider Demographics
NPI:1427458124
Name:NORTHEASTERN REPRODUCTIVE MEDICINE LABORATORIES PLLC
Entity type:Organization
Organization Name:NORTHEASTERN REPRODUCTIVE MEDICINE LABORATORIES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:R
Authorized Official - Last Name:CASSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-655-8888
Mailing Address - Street 1:105 WESTVIEW RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-8025
Mailing Address - Country:US
Mailing Address - Phone:802-655-8888
Mailing Address - Fax:802-985-2566
Practice Address - Street 1:105 WESTVIEW RD
Practice Address - Street 2:SUITE 302
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-8025
Practice Address - Country:US
Practice Address - Phone:802-655-8888
Practice Address - Fax:802-985-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT47D2079212291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1023974Medicaid
VTY300192272Medicare PIN