Basic Information
| Provider Information | |||||||||
| NPI: | 1255405197 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THANE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 LINSCOTT RD | ||||||||
| Address2: | |||||||||
| City: | HINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020434716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176679600 | ||||||||
| FaxNumber: | 6176676405 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176679600 | ||||||||
| FaxNumber: | 6176676405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 55689 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3007201 | 05 | MA | MEDICAID |