1578637658 NPI number — KURT S PETRY O.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578637658 NPI number — KURT S PETRY O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRY
Provider First Name:
KURT
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1578637658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
357C W MORGAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPENCER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47460-1219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-829-2972
Provider Business Mailing Address Fax Number:
812-829-3639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
357C W MORGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPENCER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47460-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-829-2972
Provider Business Practice Location Address Fax Number:
812-829-3639
Provider Enumeration Date:
11/20/2006

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: 152W00000X , with the licence number:  18002244B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000087919 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351787030101 . This is a "CARESOURCE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 351787030 . This is a "COMMERCIAL" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: N283918 . This is a "HARMONY HEALTH" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100193710 C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410022263 . This is a "PALMETTO GBA/RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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