Basic Information
| Provider Information | |||||||||
| NPI: | 1932293578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHERBULIEZ | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SOUTHBOROUGH DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 96 CAMPUS DR | ||||||||
| Address2: | SUITE 2C | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078837926 | ||||||||
| FaxNumber: | 2078831925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD14837 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | MD14837 | ME | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 290210099 | 05 | ME | MEDICAID | 30208173 | 05 | NH | MEDICAID |