Provider Demographics
NPI:1205941879
Name:TWIN RIVER UROLOGY
Entity type:Organization
Organization Name:TWIN RIVER UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DETZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-296-7370
Mailing Address - Street 1:108 NO MAIN ST
Mailing Address - Street 2:TWIN RIVER UROLOGY
Mailing Address - City:WHITE RIVER JCT
Mailing Address - State:VT
Mailing Address - Zip Code:05001
Mailing Address - Country:US
Mailing Address - Phone:802-296-7370
Mailing Address - Fax:802-296-7174
Practice Address - Street 1:108 NO MAIN ST
Practice Address - Street 2:TWIN RIVER UROLOGY
Practice Address - City:WHITE RIVER JCT
Practice Address - State:VT
Practice Address - Zip Code:05001
Practice Address - Country:US
Practice Address - Phone:802-296-7370
Practice Address - Fax:802-296-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8746208800000X
VT0420008456208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0573Medicaid
VT0000301OtherMEDICARE GROUP
F48766Medicare UPIN