Provider Demographics
NPI:1730160532
Name:GREEN MOUNTAIN UROLOGY INC
Entity type:Organization
Organization Name:GREEN MOUNTAIN UROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRUNERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-655-4900
Mailing Address - Street 1:792 COLLEGE PKWY
Mailing Address - Street 2:SUITE302
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-3052
Mailing Address - Country:US
Mailing Address - Phone:802-655-4900
Mailing Address - Fax:802-655-5017
Practice Address - Street 1:792 COLLEGE PKWY
Practice Address - Street 2:SUITE302
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-3052
Practice Address - Country:US
Practice Address - Phone:802-655-4900
Practice Address - Fax:802-655-5017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0583Medicaid
VT5704140001Medicare NSC
VTVN0583Medicare PIN