Provider Demographics
NPI:1043239684
Name:PETRY, ROBERT W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:PETRY
Suffix:
Gender:M
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:PO BOX 2173
Mailing Address - Street 2:
Mailing Address - City:SKYLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28776-2173
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:815 SCHNIER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-2619
Practice Address - Country:US
Practice Address - Phone:812-378-3131
Practice Address - Fax:812-379-9251
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027846A207KA0200X, 207KI0005X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN702060BMedicare PIN
IN381590AMedicare PIN
IN100052300CMedicaid
IN100052300BMedicaid
IN100052300EMedicaid
IN100470750Medicaid
IN591190BMedicare PIN
IN143490AMedicare PIN
INC24190Medicare UPIN
IN100052300DMedicaid
IN100052300AMedicaid