1639212467 NPI number — JOEL D PETTY

Table of content: JOEL D PETTY (NPI 1639212467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639212467 NPI number — JOEL D PETTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTY
Provider First Name:
JOEL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639212467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
329 2ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARABOO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53913-2459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARABOO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53913-2183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-355-4210
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1025011 . This is a "PHYSICIANS PLUS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11991 . This is a "DEAN HEALTH PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39600574011 . This is a "UNITY HEALTH INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39784200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".