1598164527 NPI number — THOMAS RAYMOND GJELTEMA DPT

Table of content: THOMAS RAYMOND GJELTEMA DPT (NPI 1598164527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598164527 NPI number — THOMAS RAYMOND GJELTEMA DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GJELTEMA
Provider First Name:
THOMAS
Provider Middle Name:
RAYMOND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598164527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 GANNETT DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-828-0361
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 CAMPUS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-523-8550
Provider Business Practice Location Address Fax Number:
207-523-8583
Provider Enumeration Date:
08/14/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT4264 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)