MEDICARE: JEAN MARIE ANTONUCCI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	12782	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12782	OTHER	ME	STATE LISENSE
2	048285	OTHER	ME	ANTHEM
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356347900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN MARIE ANTONUCCI MD

Provider Business Mailing Address
First Line	:	115 MT BLUE CIR
Second Line	:	STE 2
City	:	FARMINGTON
State	:	ME
Zip	:	04938-6239
Country	:	US
Telephone Number	:	207-778-3313
Fax Number	:	207-778-3544

Provider Business Practice Location Address
First Line	:	115 MT BLUE CIR
Second Line	:	STE 2
City	:	FARMINGTON
State	:	ME
Zip	:	04938-6239
Country	:	US
Telephone Number	:	207-778-3313
Fax Number	:	207-778-3544

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	11/15/2011

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