Provider Demographics
NPI:1639306194
Name:ROSENTHAL, JESSICA M (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:ROSENTHAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:75 JOHN ROBERTS RD STE B8
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6964
Practice Address - Country:US
Practice Address - Phone:207-775-4151
Practice Address - Fax:207-775-6950
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD21199208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400332918Medicare PIN
MEE400332938Medicare PIN