Basic Information
| Provider Information | |||||||||
| NPI: | 1144240474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTER HOSPITAL DBA CEDAR LEDGE FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 PORTER DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057538527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023888808 | ||||||||
| FaxNumber: | 8023888322 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 COURT ST | ||||||||
| Address2: | CEDAR LODGE FAMILY PRACTICE | ||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057531408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023887185 | ||||||||
| FaxNumber: | 8023883445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRINES | ||||||||
| AuthorizedOfficialFirstName: | DUNCAN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8023884701 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0VN1355 | 05 | VT | MEDICAID |