Provider Demographics
NPI:1811276868
Name:CONVENIENT MEDICAL CARE
Entity type:Organization
Organization Name:CONVENIENT MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:COURCELLE
Authorized Official - Last Name:BEDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-775-8032
Mailing Address - Street 1:25 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-3246
Mailing Address - Country:US
Mailing Address - Phone:802-775-8032
Mailing Address - Fax:802-775-3058
Practice Address - Street 1:25 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3246
Practice Address - Country:US
Practice Address - Phone:802-775-8032
Practice Address - Fax:802-775-3058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONVENIENT MEDICAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT28505Medicare UPIN