Provider Demographics
NPI:1891881447
Name:PETRUS, JAIME L (MD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:L
Last Name:PETRUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SO PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:PAVILION 1203
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-4618
Practice Address - Fax:207-662-6254
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017196208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30206869Medicaid
ME432616699Medicaid
MEP00641746Medicare PIN
NH30206869Medicaid