NPIMap

Individual provider Active NPI

Bethany Lynn Stack, P.A.

  • Medical Physician Assistant
  • Rutland, VT
National Provider Identifier
1184619876
Registry record updated Mar 3, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
055-0030670 Issued in VT
Practice address
3 Albert Cree Dr
Rutland, VT 05701-4601
Phone
(802) 775-2937
Fax
(802) 773-0934
NPI assigned
Sep 19, 2005
Last updated
Mar 3, 2011By the provider in NPPES
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Mar 3, 2011

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 055-0030670 VT Primary

Addresses

Primary practice location

3 Albert Cree Dr
Rutland, VT 05701-4601

Mailing address

3 Albert Cree Dr
Rutland, VT 05701-4601
Phone (802) 775-2937

Other identifiers 1

IdentifierTypeStateIssuer
00059907OtherVTBCBS

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VT
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040728001404 VT Practitioner - Physician Assistant 9436129277 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2003
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Rutland Hospital, Inc.Group PAC ID 7214846377, 186 clinicians

Practice addresses (Care Compare)

160 Allen St
Rutland, VT 05701-4560
Phone (802) 775-7111

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
055-0030670VTMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Rutland Hospital, Inc. Current Accepting new patients
Rutland Hospital, Inc. CurrentSince Oct 1, 2012 Accepting new patients
Rutland Hospital, Inc. CurrentSince Oct 1, 2012 Accepting new patients
Rutland Hospital, Inc. Current Accepting new patients

Locations

3902 Killington Rd
Killington, VT 05751
Phone (802) 422-1230

160 Allen St
Rutland, VT 05701

3 Albert Cree Dr
Rutland, VT 05701
Phone (802) 775-2937

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 19

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 19

NPI Registry JSON

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

{
    "created_epoch": "1127088000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1299110400000",
    "number": "1184619876",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3 ALBERT CREE DR",
            "city": "RUTLAND",
            "state": "VT",
            "postal_code": "057014601",
            "telephone_number": "802-775-2937",
            "fax_number": "802-773-0934"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3 ALBERT CREE DR",
            "city": "RUTLAND",
            "state": "VT",
            "postal_code": "057014601",
            "telephone_number": "802-775-2937",
            "fax_number": "802-773-0934"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "STACK",
        "first_name": "BETHANY",
        "middle_name": "LYNN",
        "credential": "P.A.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2005-09-19",
        "last_updated": "2011-03-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "VT",
            "license": "055-0030670",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "00059907",
            "state": "VT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Rutland, VT

Sources for this page

Verify at the official NPI Registry.