1215007646 NPI number — MARY RUTH MAGLIONE MACP,LADC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215007646 NPI number — MARY RUTH MAGLIONE MACP,LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAGLIONE
Provider First Name:
MARY
Provider Middle Name:
RUTH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MACP,LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215007646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
339 KNIPES DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARENDON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-775-1601
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 GRANGER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-4405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-747-3588
Provider Business Practice Location Address Fax Number:
802-775-7196
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  000155 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00049582 . This is a "BCBS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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