Provider Demographics
NPI:1902144405
Name:PETER C. STICKNEY, MD PC
Entity Type:Organization
Organization Name:PETER C. STICKNEY, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:STICKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-773-2626
Mailing Address - Street 1:69 ALLEN ST
Mailing Address - Street 2:SUITE #5
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4590
Mailing Address - Country:US
Mailing Address - Phone:802-773-2626
Mailing Address - Fax:802-773-5245
Practice Address - Street 1:69 ALLEN ST
Practice Address - Street 2:SUITE #5
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4590
Practice Address - Country:US
Practice Address - Phone:802-773-2626
Practice Address - Fax:802-773-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420004909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004494Medicaid
VTVT4494Medicare UPIN