Provider Demographics
NPI:1255405197
Name:THANE, MICHAEL WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:THANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 LINSCOTT RD
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-4716
Mailing Address - Country:US
Mailing Address - Phone:617-667-9600
Mailing Address - Fax:617-667-6405
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-9600
Practice Address - Fax:617-667-6405
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3007201Medicaid
B74676Medicare UPIN
MA3007201Medicaid