Provider Demographics
NPI:1902132608
Name:MARK YORRA
Entity Type:Organization
Organization Name:MARK YORRA
Other - Org Name:GRANITE CITY MEDICAL ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:YORRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-479-2546
Mailing Address - Street 1:30 KEITH AVE
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-3729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 KEITH AVE
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-3729
Practice Address - Country:US
Practice Address - Phone:802-479-2546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0015040Medicare PIN