Healthcare Provider Details

I. General information

NPI: 1235349879
Provider Name (Legal Business Name): JANE GLASS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SEWALL STREET SUITE 301
PORTLAND ME
04102
US

IV. Provider business mailing address

46 FOREST RD
CAPE ELIZABETH ME
04107-1341
US

V. Phone/Fax

Practice location:
  • Phone: 207-780-6631
  • Fax: 207-780-6320
Mailing address:
  • Phone: 207-838-0049
  • Fax: 207-780-6320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1249
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: