Provider Demographics
NPI:1033175682
Name:PETRI, JAN H (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:H
Last Name:PETRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9554 FOX HILL CIR S
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-6829
Mailing Address - Country:US
Mailing Address - Phone:901-861-2526
Mailing Address - Fax:901-861-2527
Practice Address - Street 1:2028 W POPLAR AVE STE 112
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0618
Practice Address - Country:US
Practice Address - Phone:901-861-2526
Practice Address - Fax:901-861-2527
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17612207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3073227Medicaid
F49591Medicare UPIN
TN3073227Medicaid
TN3718614Medicare PIN
TNCG5243Medicare PIN
MSC02615Medicare PIN