Basic Information
| Provider Information | |||||||||
| NPI: | 1891881447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRUS | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 WALLACE AVE | ||||||||
| Address2: | |||||||||
| City: | SO PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077610650 | ||||||||
| FaxNumber: | 2077618198 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 BRAMHALL ST | ||||||||
| Address2: | PAVILION 1203 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076624618 | ||||||||
| FaxNumber: | 2076626254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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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 | 208000000X | 017196 | ME | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 30206869 | 05 | NH | MEDICAID | 432616699 | 05 | ME | MEDICAID |