Provider Demographics
NPI:1609941509
Name:SOUTHERN MAINE GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:SOUTHERN MAINE GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-467-9156
Mailing Address - Street 1:PMB 2700
Mailing Address - Street 2:4 SCAMMON ST, SUITE 19
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072
Mailing Address - Country:US
Mailing Address - Phone:207-282-4704
Mailing Address - Fax:207-286-3218
Practice Address - Street 1:10 STORER ST
Practice Address - Street 2:UNIT 106, LAFAYETTE CENTER
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6875
Practice Address - Country:US
Practice Address - Phone:207-467-9156
Practice Address - Fax:207-467-9157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1428193OtherAETNA
ME878196OtherCIGNA
ME432448100Medicaid
MEDF4665Medicare PIN
MEME2292Medicare PIN