Provider Demographics
NPI:1700826203
Name:PROVOST, THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PROVOST
Suffix:
Gender:M
Credentials:DO
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 845614
Mailing Address - Street 2:CHESHIRE ANESTHESIA
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-5614
Mailing Address - Country:US
Mailing Address - Phone:800-720-1664
Mailing Address - Fax:207-753-2020
Practice Address - Street 1:580 COURT ST
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1715
Practice Address - Country:US
Practice Address - Phone:603-354-5454
Practice Address - Fax:603-354-5428
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH10633207LP2900X, 208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30220464Medicaid
050071165OtherRAILROAD MEDICARE
NHG11952Medicare UPIN