Healthcare Provider Details

I. General information

NPI: 1740212364
Provider Name (Legal Business Name): MARC P JACQUET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST PAVILLION 1203
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 207-662-4618
  • Fax: 207-662-6254
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD14727
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD14727
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: