Provider Demographics
NPI:1598803553
Name:POULIN, THOMAS G
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:G
Last Name:POULIN
Suffix:
Gender:M
Credentials:
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 217
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0217
Mailing Address - Country:US
Mailing Address - Phone:207-990-5001
Mailing Address - Fax:
Practice Address - Street 1:199 CEDAR ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4638
Practice Address - Country:US
Practice Address - Phone:207-944-5501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 1790174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist