Basic Information
| Provider Information | |||||||||
| NPI: | 1376504878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 US ROUTE ONE | ||||||||
| Address2: | BUILDING C | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 2073968632 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 BRAMHALL ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076623157 | ||||||||
| FaxNumber: | 2076624257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | G69789 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | 013843 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 013843 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 337580099 | 05 | ME | MEDICAID |