1407045644 NPI number — ANITA PETTEWAY MD

Table of content: ANITA PETTEWAY MD (NPI 1407045644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407045644 NPI number — ANITA PETTEWAY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTEWAY
Provider First Name:
ANITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1407045644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 N MIAMI BEACH BLVD
Provider Second Line Business Mailing Address:
SUITE 503
Provider Business Mailing Address City Name:
NORTH MIAMI BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33162-3712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-944-8887
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 N MIAMI BEACH BLVD
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
NORTH MIAMI BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33162-3712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-944-8887
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2007

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: 207R00000X , with the licence number:  ME69729 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3421617 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 31947 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 250632700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 259904 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2054109 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 25649 . This is a "NHP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 102350000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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