Provider Demographics
NPI:1063456523
Name:THIBODEAU, LEE L (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:L
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PARKWAY
Mailing Address - Street 2:SUITE 490
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-0000
Mailing Address - Country:US
Mailing Address - Phone:207-553-6054
Mailing Address - Fax:207-553-6076
Practice Address - Street 1:195 FORE RIVER PKWY
Practice Address - Street 2:SUITE 490
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2780
Practice Address - Country:US
Practice Address - Phone:207-553-6054
Practice Address - Fax:207-553-6076
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME012489207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003392Medicaid
ME245520099Medicaid
MEMM1156Medicare PIN
MEB86452Medicare UPIN
MEMM115601Medicare PIN
NH30003392Medicaid