Provider Demographics
NPI:1346263712
Name:PETRIN, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PETRIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11911 N. MERIDIAN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46032
Mailing Address - Country:US
Mailing Address - Phone:317-621-6800
Mailing Address - Fax:
Practice Address - Street 1:11911 N. MERIDIAN
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-621-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024966A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000313296OtherANTHEM
INP00092387OtherRR MEDICARE
INP00092387OtherRR MEDICARE
IN000000313296OtherANTHEM