Provider Demographics
NPI:1730148966
Name:MAD RIVER INTERNAL MEDICINE
Entity type:Organization
Organization Name:MAD RIVER INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WARGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-496-2202
Mailing Address - Street 1:5360 MAIN ST
Mailing Address - Street 2:STE. 2
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673-6003
Mailing Address - Country:US
Mailing Address - Phone:802-496-2202
Mailing Address - Fax:802-496-2223
Practice Address - Street 1:5360 MAIN ST
Practice Address - Street 2:STE. 2
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673-6003
Practice Address - Country:US
Practice Address - Phone:802-496-2202
Practice Address - Fax:802-496-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012198Medicaid
VT1012198Medicaid