Basic Information
| Provider Information | |||||||||
| NPI: | 1508874314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCY | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | WENDELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 LYMAN DR | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054958865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028788316 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | ACC EAST PAVILION 5 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028471158 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | VT 042 0008686 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 01385033 | 05 | NY | MEDICAID | 0VN0575 | 05 | VT | MEDICAID |