1447340302 NPI number — DR. BRIAN RICHARD PETRIE D.C.

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 1447340302 NPI number — DR. BRIAN RICHARD PETRIE D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRIE
Provider First Name:
BRIAN
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1447340302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
575 SOUTH ST W
Provider Second Line Business Mailing Address:
UNIT 2
Provider Business Mailing Address City Name:
RAYNHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02767-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-821-4049
Provider Business Mailing Address Fax Number:
508-821-2526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 SOUTH ST W
Provider Second Line Business Practice Location Address:
UNIT 2
Provider Business Practice Location Address City Name:
RAYNHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02767-5305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-821-4049
Provider Business Practice Location Address Fax Number:
508-821-2526
Provider Enumeration Date:
10/13/2006

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: 111N00000X , with the licence number:  1824 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Y36303 . This is a "BC/BS OF MA PROVIDER NO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1601580 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 335503 . This is a "TUFTS OUT OF NETWORK ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 401417 . This is a "BLUE CHIP RI ID NO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: ZY39272 . This is a "BC/BS MA GROUP ID NO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4981-2 . This is a "BC/BS RI PROVIDER NO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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