Basic Information
| Provider Information | |||||||||
| NPI: | 1124027628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTY | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | MILLER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043761605 | ||||||||
| FaxNumber: | 7043358448 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043761605 | ||||||||
| FaxNumber: | 7043358448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 11925 | NC | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 140004695 | 01 | RAILROAD MEDICARE | OTHER | 453681 | 05 | SC | MEDICAID | 8967385 | 05 | NC | MEDICAID |