Provider Demographics
NPI:1932293578
Name:CHERBULIEZ, NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CHERBULIEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:96 CAMPUS DR
Practice Address - Street 2:SUITE 2C
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7163
Practice Address - Country:US
Practice Address - Phone:207-883-7926
Practice Address - Fax:207-883-1925
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD14837207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME290210099Medicaid
NH30208173Medicaid
MEP00971129Medicare PIN
MEMM737601Medicare PIN
G74502Medicare UPIN
ME080194098Medicare PIN
MEMM737603Medicare PIN
NH30208173Medicaid
MEMM737602Medicare PIN