Provider Demographics
NPI:1134397557
Name:PHILIP R. POULIN, O.D.
Entity type:Organization
Organization Name:PHILIP R. POULIN, O.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:POULIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-871-7553
Mailing Address - Street 1:87 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-5001
Mailing Address - Country:US
Mailing Address - Phone:207-871-7553
Mailing Address - Fax:
Practice Address - Street 1:87 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5001
Practice Address - Country:US
Practice Address - Phone:207-871-7553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME712T305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEUX3386Medicare UPIN