MEDICARE: DIANA L JEANNOTTE M.D.

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	MD10480	ME

General Provider Information

NPI Number	:	1568467470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA L JEANNOTTE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 468
Second Line	:
City	:	SKOWHEGAN
State	:	ME
Zip	:	04976-0468
Country	:	US
Telephone Number	:	207-858-8353
Fax Number	:	207-474-9261

Provider Business Practice Location Address
First Line	:	62 MAIN ST
Second Line	:
City	:	SKOWHEGAN
State	:	ME
Zip	:	04976-1146
Country	:	US
Telephone Number	:	207-858-4844
Fax Number	:	207-858-0348

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	12/20/2017

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