Basic Information
| Provider Information | |||||||||
| NPI: | 1689652372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 E APPLE ST | ||||||||
| Address2: | STE 3300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372088394 | ||||||||
| FaxNumber: | 9372088388 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E APPLE ST | ||||||||
| Address2: | STE 3300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372088394 | ||||||||
| FaxNumber: | 9372088388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
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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 | 208M00000X | 35-051279 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 35.051279 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0593666 | 05 | OH | MEDICAID |