Basic Information
| Provider Information | |||||||||
| NPI: | 1144487638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KURT S. PETRY OD, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SPENCER COMMUNITY EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 357C W MORGAN ST | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474601219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128292972 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 357C W MORGAN ST | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474601219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128292972 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 03/01/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETRY | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8128292972 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KURT S. PETRY OD, PC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18002244B | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 100193710 | 05 | IN | MEDICAID | 000000087919 | 01 | IN | BCBS | OTHER |