1174734818 NPI number — DR. GRETCHEN G PETTERWAY MD

Table of content: DR. GRETCHEN G PETTERWAY MD (NPI 1174734818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174734818 NPI number — DR. GRETCHEN G PETTERWAY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTERWAY
Provider First Name:
GRETCHEN
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
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:
GILLYARD
Provider Other First Name:
GRETCHEN
Provider Other Middle Name:
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:
1174734818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
919 HIDDEN RDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75038-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-282-2711
Provider Business Mailing Address Fax Number:
469-282-0996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9220 ELLERBE RD
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71106-6739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-681-5282
Provider Business Practice Location Address Fax Number:
318-681-5284
Provider Enumeration Date:
05/24/2007

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: 208000000X , with the licence number:  MD.202577 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1079219 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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