Provider Demographics
NPI:1801903406
Name:THACKERAY, CARRIE (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:THACKERAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7 MADELYN LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4460
Mailing Address - Country:US
Mailing Address - Phone:207-593-5900
Mailing Address - Fax:207-593-5358
Practice Address - Street 1:7 MADELYN LN
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4460
Practice Address - Country:US
Practice Address - Phone:207-593-5900
Practice Address - Fax:207-593-5358
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME016623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEI25001Medicare UPIN