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General NPI Number Information
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NPI Number | 1891881447
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Entity Type | Individual
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Provider Name | JAIME L PETRUS MD
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Gender | Female
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 02/23/2009
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Provider Practice Location Address
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Address Line | 22 BRAMHALL ST PAVILION 1203
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City | PORTLAND
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State | ME
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Zip | 04102
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Country | US
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Telephone | 207-662-4618
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Fax | 207-662-6254
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Provider Business Mailing Address
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Address Line | 39 WALLACE AVE
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City | SO PORTLAND
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State | ME
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Zip | 04106
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Country | US
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Telephone | 207-761-0650
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Fax | 207-761-8198
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 017196
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License Number State | ME
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