Healthcare Provider Details

I. General information

NPI: 1851347314
Provider Name (Legal Business Name): THOMAS M KINKEAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BRICKHILL AVE
SOUTH PORTLAND ME
04106-1999
US

IV. Provider business mailing address

301 US ROUTE 1 BUILDING C
SCARBOROUGH ME
04074-7609
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-1728
  • Fax: 207-772-4062
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD13629
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberMD13629
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: