NPIMap

Individual provider Active NPI

Shayne Poulin, M.D.

  • Family Medicine Physician
  • San Bernardino, CA
National Provider Identifier
1184915407
Registry record updated May 12, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
146174 Issued in CA
Practice address
1873 Commercenter W
San Bernardino, CA 92408-3303
Phone
(909) 890-5511
Fax
(866) 886-7824
NPI assigned
Apr 20, 2011
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 12, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 260709 MA
Family Medicine Physician 207Q00000X 146174 CA Primary

Addresses

Primary practice location

1873 Commercenter W
San Bernardino, CA 92408-3303

Mailing address

700 S Tustin St
Orange, CA 92866-3425
Phone (714) 922-4100

Other identifiers 1

IdentifierTypeStateIssuer
110097301AMedicaidMA

Other names 1

  • Shayne Thompson Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
146174CAMDMarriage & Family Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Boston Medical Center Corporation Past Accepting new patients
Anaheim Memorial Medical Center Past Accepting new patients
Hoag Memorial Hospital Presbyterian Past Accepting new patients
Planned Parenthood/Orange and San Bernardino Counties, Inc. Past Accepting new patients
Planned Parenthood/Orange and San Bernardino Counties, Inc. Past Accepting new patients

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1303257600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1494547200000",
    "number": "1184915407",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "700 S TUSTIN ST",
            "city": "ORANGE",
            "state": "CA",
            "postal_code": "928663425",
            "telephone_number": "714-922-4100",
            "fax_number": "866-886-7824"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1873 COMMERCENTER W",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924083303",
            "telephone_number": "909-890-5511",
            "fax_number": "866-886-7824"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "POULIN",
        "first_name": "SHAYNE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-04-20",
        "last_updated": "2017-05-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MA",
            "license": "260709",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CA",
            "license": "146174",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "110097301A",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "SHAYNE",
            "last_name": "THOMPSON",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in San Bernardino, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 12, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.