Basic Information
| Provider Information | |||||||||
| NPI: | 1962729442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTI | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SOUTHBOROUGH DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 96 CAMPUS DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078859905 | ||||||||
| FaxNumber: | 2073965600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 08/26/2016 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | MD20969 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | MD20969 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1962729442 | 05 | ME | MEDICAID |