Provider Demographics
NPI:1902100928
Name:CHAMPLAIN VALLEY ANESTHESIA, PLLC
Entity Type:Organization
Organization Name:CHAMPLAIN VALLEY ANESTHESIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:IANNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-462-3225
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:P.O. BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:115 PORTER DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-8423
Practice Address - Country:US
Practice Address - Phone:802-388-4724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty