Provider Demographics
NPI:1134125164
Name:PETRE, ANNE M (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:PETRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:M
Other - Last Name:PENAVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4281
Mailing Address - Country:US
Mailing Address - Phone:309-796-2329
Mailing Address - Fax:309-796-1146
Practice Address - Street 1:306 46TH AVE
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4281
Practice Address - Country:US
Practice Address - Phone:309-796-2329
Practice Address - Fax:309-796-1146
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091695207Q00000X
IL036-091695207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
020355OtherHEALTH ALLIANCE
IL01F1OtherJOHN DEERE
20083OtherIOWA HEALTH SOLUTIONS
90800OtherWELLMARK BC/BS
IL036091695Medicaid
4796890020OtherDMERC
4796890020OtherDMERC
020355OtherHEALTH ALLIANCE
IL01F1OtherJOHN DEERE