Basic Information
| Provider Information | |||||||||
| NPI: | 1366496887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETROCY | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 VAN BUREN RD | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047363567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074935791 | ||||||||
| FaxNumber: | 2074981326 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 VAN BUREN RD | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047363567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074935791 | ||||||||
| FaxNumber: | 2074981326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD21228 | ME | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 08330226 | 05 | MS | MEDICAID | 1423777 | 05 | LA | MEDICAID | 2574254 | 05 | OH | MEDICAID |