Provider Demographics
NPI:1669069126
Name:HEARTH STONE INTERNAL MEDICINE, LLC
Entity type:Organization
Organization Name:HEARTH STONE INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAN DYCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-667-6272
Mailing Address - Street 1:242 WANTASTIQUET DR
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6041
Mailing Address - Country:US
Mailing Address - Phone:603-667-6272
Mailing Address - Fax:
Practice Address - Street 1:152 GRAFTON RD
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353
Practice Address - Country:US
Practice Address - Phone:603-667-6272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty