MEDICARE: DR. CHARLENE MARIE THOMESEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician	168653	NY
2	2084P0800X	Psychiatry Physician	168653	NY

General Provider Information

NPI Number	:	1437126257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLENE MARIE THOMESEN M.D.

Provider Business Mailing Address
First Line	:	79 MIDDLEVILLE RD # 116A
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-2200
Country	:	US
Telephone Number	:	631-754-7963
Fax Number	:	631-754-9350

Provider Business Practice Location Address
First Line	:	79 MIDDLEVILLE RD # 116A
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-2200
Country	:	US
Telephone Number	:	631-754-7963
Fax Number	:	631-754-9350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	07/11/2007

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