Provider Demographics
NPI:1922047505
Name:THALLER, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:THALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ENTERPRISE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-7894
Mailing Address - Country:US
Mailing Address - Phone:207-621-8700
Mailing Address - Fax:207-621-8701
Practice Address - Street 1:15 ENTERPRISE DR
Practice Address - Street 2:STE 100
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7894
Practice Address - Country:US
Practice Address - Phone:207-621-8700
Practice Address - Fax:207-621-8701
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017126207X00000X
MEMD17126207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432326199Medicaid
ME432326199Medicaid
MEP00404406Medicare PIN
MEME2028Medicare ID - Type Unspecified
MEME202801Medicare PIN