Provider Demographics
NPI:1508858549
Name:MAYCOCK, THOMAS ROLAND (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROLAND
Last Name:MAYCOCK
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 1:9 FAHEY ST
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6028
Mailing Address - Country:US
Mailing Address - Phone:207-338-1120
Mailing Address - Fax:207-338-1691
Practice Address - Street 1:9 FAHEY ST
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6028
Practice Address - Country:US
Practice Address - Phone:207-338-1120
Practice Address - Fax:207-338-1691
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME008970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME118460000Medicaid
010430165OtherSTANDARD INS
012002OtherANTHEM
1041723OtherAETNA
1041723OtherAETNA
010430165OtherSTANDARD INS