Provider Demographics
NPI:1366496887
Name:PETROCY, PAMELA JOAN (MD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JOAN
Last Name:PETROCY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 VAN BUREN RD
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-3567
Mailing Address - Country:US
Mailing Address - Phone:207-493-5791
Mailing Address - Fax:207-498-1326
Practice Address - Street 1:163 VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-3567
Practice Address - Country:US
Practice Address - Phone:207-493-5791
Practice Address - Fax:207-498-1326
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD21228207X00000X
LAMD.025021207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08330226Medicaid
LA1423777Medicaid
OH2574254Medicaid
LA255686YH3UMedicare PIN
OH127582Medicare UPIN
LA4Q094Medicare PIN
OHPE4155191Medicare PIN