Basic Information
| Provider Information | |||||||||
| NPI: | 1013274745 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHAMPLAIN IMAGING | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHAMPLAIN IMAGING, PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8002 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030798002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 FAIRFIELD ST | ||||||||
| Address2: | |||||||||
| City: | SAINT ALBANS | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054781726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | LOPATINA | ||||||||
| AuthorizedOfficialFirstName: | OLGA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8025241209 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 102151 | 05 | VT | MEDICAID |