Provider Demographics
NPI:1588790562
Name:EVERGREEN FAMILY HEALTH PARTNERS
Entity type:Organization
Organization Name:EVERGREEN FAMILY HEALTH PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-878-1008
Mailing Address - Street 1:426 INDUSTRIAL AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4449
Mailing Address - Country:US
Mailing Address - Phone:802-878-1008
Mailing Address - Fax:802-872-2679
Practice Address - Street 1:426 INDUSTRIAL AVE STE 130
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4449
Practice Address - Country:US
Practice Address - Phone:802-878-1008
Practice Address - Fax:802-872-2679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008514Medicaid
VT1008514Medicaid