Provider Demographics
NPI:1275544116
Name:PETRIE, BEVERLEY (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLEY
Middle Name:
Last Name:PETRIE
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 1:21840 NORMANDIE AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2047
Mailing Address - Country:US
Mailing Address - Phone:310-222-5015
Mailing Address - Fax:310-222-5027
Practice Address - Street 1:21840 NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2047
Practice Address - Country:US
Practice Address - Phone:310-222-5015
Practice Address - Fax:310-222-5027
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55817208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A558170Medicaid
CAWA55817DMedicare PIN
CAWA55817CMedicare PIN
CAA55817Medicare PIN
CAWA55817BMedicare UPIN
CA00A558170Medicaid