Basic Information
| Provider Information | |||||||||
| NPI: | 1265653992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRIE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EARL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 356 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672010356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003745326 | ||||||||
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| Practice Location | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003745326 | ||||||||
| FaxNumber: | 8003747656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 09/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 6367 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 0432621 | KS | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 200608960A | 05 | KS | MEDICAID | P00727381 | 01 | KS | RR MEDICARE GROUP# CQ2302 | OTHER |