1134125164 NPI number — ANNE M PETRE MD

Table of content: ANNE M PETRE MD (NPI 1134125164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134125164 NPI number — ANNE M PETRE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRE
Provider First Name:
ANNE
Provider Middle Name:
M
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:
PENAVA
Provider Other First Name:
ANNE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134125164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306 46TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61244-4281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-796-2329
Provider Business Mailing Address Fax Number:
309-796-1146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 46TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61244-4281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-796-2329
Provider Business Practice Location Address Fax Number:
309-796-1146
Provider Enumeration Date:
06/23/2005

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: 207Q00000X , with the licence number:  036091695 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 036-091695 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 020355 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: IL01F1 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20083 . This is a "IOWA HEALTH SOLUTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 90800 . This is a "WELLMARK BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036091695 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4796890020 . This is a "DMERC" identifier . This identifiers is of the category "OTHER".




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