# BROOKSIDE PEDIATRICS & ADOLESCENT MEDICINE PLLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1568578656
- **Authorized official:** THEODORE L JOHNSON MD (OWNER)
- **Authorized official phone:** (802) 442-2264

## Contact information

- **Practice address:** 194 NORTH STREET, BENNINGTON, VT 05201
- **Practice address phone:** (802) 442-2264
- **Practice address fax:** (802) 442-2337
- **Mailing address:** 194 NORTH STREET, BENNINGTON, VT 05201
- **Mailing address phone:** (802) 442-2264
- **Mailing address fax:** (802) 442-2337

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208000000X | Pediatrics Physician | — | NULL | Yes |
| 208000000X | Pediatrics Physician | — | — | Yes |

## Other

- **Enumeration date:** 08/22/2006
- **Last updated:** 10/04/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1007123 | — | VT |