1891879094 NPI number — JENNIFER PETRIE MD

Table of content: JENNIFER PETRIE MD (NPI 1891879094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891879094 NPI number — JENNIFER PETRIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRIE
Provider First Name:
JENNIFER
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:
1891879094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 E QUAIL RUN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMMETT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83617-5059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-365-7131
Provider Business Mailing Address Fax Number:
208-365-4464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 E QUAIL RUN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617-5059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-365-7131
Provider Business Practice Location Address Fax Number:
208-365-4464
Provider Enumeration Date:
10/24/2006

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: 207Q00000X , with the licence number:  M7802 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 101703 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 136314 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP51751 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8051964 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043689 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 317180900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34623200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-20325 . This is a "MEDICA CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01-20325 . This is a "MEDICA PRIMARY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0591172 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20008330 . This is a "PTAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 2349340 . This is a "ARAZ" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com