Basic Information
| Provider Information | |||||||||
| NPI: | 1477640472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORMIER | ||||||||
| FirstName: | MARLENE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 174 S FREEPORT RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040326145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078651819 | ||||||||
| FaxNumber: | 2078654535 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040112652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077290181 | ||||||||
| FaxNumber: | 2077291457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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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 | 207P00000X | 012505 | ME | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | B92955 | 01 | ME | HARVARD PILGRIM | OTHER | 043461 | 01 | ME | ANTHEM | OTHER | 1610384002 | 01 | ME | CIGNA | OTHER | 1477640472 | 01 | ME | TRICARE | OTHER |