Basic Information
| Provider Information | |||||||||
| NPI: | 1154384485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 LONG SANDS RD | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | YORK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 039091159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073638430 | ||||||||
| FaxNumber: | 2073513006 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 LONG SANDS RD | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | YORK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 039091159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073638430 | ||||||||
| FaxNumber: | 2073513006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 04/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME014829 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010467585 | 01 | MACHIGONNE | OTHER | 080140514 | 01 | RAILROAD MEDICARE | OTHER | 271500099 | 01 | PRIMECARE MEDICAID | OTHER | 271500099 | 05 | ME | MEDICAID | 010467585 | 01 | STANDARD TAX ID | OTHER | 027332 | 01 | ANTHEM BCBS | OTHER | 6960100 | 01 | CIGNA HEALTHCARE | OTHER | 0100365YPME01 | 01 | NH | ANTHEM BCBS NEW HAMPSHIRE | OTHER | 010467585 | 01 | AETNA HMO | OTHER | 010467585 | 01 | AETNA NONHMO | OTHER | F83718 | 01 | HARVARD PILGRIM | OTHER |