Provider Demographics
NPI:1285665828
Name:MARINO, RICHARD T JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:MARINO
Suffix:JR
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 1:190 RIVERSIDE ST UNIT 6B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:66 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3344
Practice Address - Country:US
Practice Address - Phone:207-662-3157
Practice Address - Fax:207-662-4257
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD16511207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME072604Medicare PIN
MEME072601Medicare PIN
MEP01118931Medicare PIN
MEME072605Medicare PIN
MEME072603Medicare PIN
I10080Medicare UPIN
MEME072602Medicare PIN
MEP00244246Medicare PIN
MEME0726Medicare PIN
MESX3273Medicare PIN