Provider Demographics
NPI:1114128808
Name:PETRIE, MATTHEW SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SHANE
Last Name:PETRIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3055 WASHINGTON RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-3279
Mailing Address - Country:US
Mailing Address - Phone:724-260-5424
Mailing Address - Fax:724-260-5425
Practice Address - Street 1:3055 WASHINGTON RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-3279
Practice Address - Country:US
Practice Address - Phone:724-260-5424
Practice Address - Fax:724-260-5425
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD72126207ND0101X, 207N00000X, 207ND0101X
PAMD438908207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102851711-0002Medicaid
NC60182BMedicare UPIN
PA102851711-0002Medicaid