Healthcare Provider Details

I. General information

NPI: 1336433085
Provider Name (Legal Business Name): JACOB EMERSON CROTHERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2011
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SAINT JOHN ST STE 322
PORTLAND ME
04102-3059
US

IV. Provider business mailing address

222 SAINT JOHN ST STE 322
PORTLAND ME
04102-3059
US

V. Phone/Fax

Practice location:
  • Phone: 207-560-3422
  • Fax:
Mailing address:
  • Phone: 207-560-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number052724
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number052724
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberMD20886
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: