Basic Information
| Provider Information | |||||||||
| NPI: | 1093997249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTER HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORTER HOSPITAL INC DBA BRISTOL INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 PORTER DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057538527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023885682 | ||||||||
| FaxNumber: | 8023885692 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 PARK PL | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054431229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024537422 | ||||||||
| FaxNumber: | 8024533071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 07/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | CIAMPA | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8023885752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PORTER HOSPITAL INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1014490 | 05 | VT | MEDICAID |