Basic Information
| Provider Information | |||||||||
| NPI: | 1841256690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROCKWELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 RIVERSIDE ST | ||||||||
| Address2: | SUITE 6B | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 US ROUTE ONE | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078857700 | ||||||||
| FaxNumber: | 2078857701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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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 | 207R00000X | 188147 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD18694 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 188147 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | MD18694 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 15811 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 01283389 | 05 | NY | MEDICAID |