| Jon Petruschke Llc | |
|
145 Newbury St Suite 2 Portland ME 04101-4261 | |
| (207) 774-9667 | |
| Not Available |
| Full Name | Jon Petruschke Llc |
|---|---|
| Speciality | Social Worker |
| Location | 145 Newbury St, Portland, Maine |
| Authorized Official Name and Position | Jon Petruschke (SOCIAL WORKER) |
| Authorized Official Contact | 2077749667 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Jon Petruschke Llc 21 Howard St Portland ME 04101-3208 Ph: (207) 774-9667 | Jon Petruschke Llc 145 Newbury St Suite 2 Portland ME 04101-4261 Ph: (207) 774-9667 |
| NPI Number | 1528593985 |
|---|---|
| Provider Enumeration Date | 04/24/2017 |
| Last Update Date | 04/24/2017 |
| Medicare PECOS PAC ID | 4688941164 |
|---|---|
| Medicare Enrollment ID | O20170605001992 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1528593985 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Jon Petruschke |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1306021910 PECOS PAC ID: 5597032078 Enrollment ID: I20170605002099 |
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