Basic Information
| Provider Information | |||||||||
| NPI: | 1841510252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRIE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 520 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096777003 | ||||||||
| FaxNumber: | 2673393761 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 LIONEL WAY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444074070 | ||||||||
| FaxNumber: | 4077433050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2010 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME127696 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 018113200 | 05 | FL | MEDICAID | ME127696 | 01 | FL | MEDICAL LICENSE | OTHER |