Healthcare Provider Details

I. General information

NPI: 1144415258
Provider Name (Legal Business Name): JAMES BRIAN BERUBE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SANFORD RD
WELLS ME
04090-5533
US

IV. Provider business mailing address

112 SANFORD RD
WELLS ME
04090-5533
US

V. Phone/Fax

Practice location:
  • Phone: 207-646-0373
  • Fax:
Mailing address:
  • Phone: 207-646-0373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3022
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: