Provider Demographics
NPI:1033182019
Name:POLKINGHORN, GEORGE RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:RICHARD
Last Name:POLKINGHORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0911
Mailing Address - Country:US
Mailing Address - Phone:207-885-7601
Mailing Address - Fax:207-885-7610
Practice Address - Street 1:81 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 1300
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2690
Practice Address - Country:US
Practice Address - Phone:207-729-1148
Practice Address - Fax:207-729-2789
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME14286207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME335540099Medicaid
ME830006189OtherRAILROAD MEDICARE
ME335540099Medicaid
MM7353Medicare PIN
A93404Medicare UPIN