NPIMap

Organization Active NPI

Green Mountain Dermatology PLLC

Doing business as Four Seasons Dermatology

  • Dermatology Physician
  • Colchester, VT
National Provider Identifier
1093577827
Registry record updated Oct 11, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
GREEN MOUNTAIN DERMATOLOGY PLLC
Doing business as
Four Seasons Dermatology
Practice address
354 Mountain View Dr
Colchester, VT 05446-5968
Phone
(802) 864-0192
NPI assigned
Jan 26, 2024
Last updated
Oct 11, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 11, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer Haley, MD
Title
Authorized Official
Phone
(561) 314-2000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X NU Primary

Addresses

Primary practice location

354 Mountain View Dr
Colchester, VT 05446-5968

Mailing address

4700 Exchange CT Ste 100
Boca Raton, FL 33431-4450
Phone (561) 314-2000

Other practice location 1

2 Healey Ave
Plattsburgh, NY 12901-2413
Phone (802) 864-0192

Other names 1

  • Four Seasons Dermatology Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VT, NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20240322000288 VT Part B Supplier - Clinic/Group Practice 4688011992 Receives reassigned benefits from 16 practitioners
Practice locations: Waterbury, VT; Rutland, VT; Colchester, VT
O20241008002263 NY Part B Supplier - Clinic/Group Practice 4688011992 Receives reassigned benefits from 9 practitioners
Practice locations: Plattsburgh, NY

National Provider Directory

National Provider Directory

Locations

4700 Exchange Ct
Ste 100
Boca Raton, FL 33431

2 Healey Ave
Ste 150
Plattsburgh, NY 12901

354 Mountain View Dr
Colchester, VT 05446
Phone (802) 658-4447

253 Stratton Rd
Rutland, VT 05701

28 Stowe St
Ste 3
Waterbury, VT 05676
Phone (802) 864-0492

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1706227200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728604800000",
    "number": "1093577827",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 EXCHANGE CT STE 100",
            "city": "BOCA RATON",
            "state": "FL",
            "postal_code": "334314450",
            "telephone_number": "561-314-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "354 MOUNTAIN VIEW DR",
            "city": "COLCHESTER",
            "state": "VT",
            "postal_code": "054465968",
            "telephone_number": "802-864-0192"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2 Healey Ave",
            "address_purpose": "LOCATION",
            "city": "Plattsburgh",
            "state": "NY",
            "postal_code": "129012413",
            "country_code": "US",
            "telephone_number": "802-864-0192",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "GREEN MOUNTAIN DERMATOLOGY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-01-26",
        "last_updated": "2024-10-11",
        "certification_date": "2024-10-11",
        "status": "A",
        "authorized_official_last_name": "HALEY",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "561-314-2000",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Four Seasons Dermatology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Colchester, VT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.