Basic Information
| Provider Information | |||||||||
| NPI: | 1164993853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRY | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETRY | ||||||||
| OtherFirstName: | MAGGIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN-CNM | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3230 VETERANS MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628645950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189975266 | ||||||||
| FaxNumber: | 6189975285 | ||||||||
| Practice Location | |||||||||
| Address1: | 3595 SKY HAWK DR | ||||||||
| Address2: | |||||||||
| City: | SHILOH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622214465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183347416 | ||||||||
| FaxNumber: | 9046158373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2018 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 209-018500 | IL | N | Other Service Providers | Midwife |
No ID Information.