Basic Information
| Provider Information | |||||||||
| NPI: | 1235322561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIBEAULT | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 HOSPITAL DR | ||||||||
| Address2: | YORK HOSPITAL | ||||||||
| City: | YORK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 039091011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073512143 | ||||||||
| FaxNumber: | 2073512143 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 SANFOR ROAD (RT. 109) | ||||||||
| Address2: | WELLS PHYSICAL THERAPY | ||||||||
| City: | WELLS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076460373 | ||||||||
| FaxNumber: | 2076460381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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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 | 225100000X | PT758 | ME | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.