Provider Demographics
NPI:1477661361
Name:PETTY, ELIZABETH M (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:M
Last Name:PETTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:RUTH
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 LANTANA RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-1903
Mailing Address - Country:US
Mailing Address - Phone:931-484-5141
Mailing Address - Fax:931-484-5620
Practice Address - Street 1:100 LANTANA RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-1903
Practice Address - Country:US
Practice Address - Phone:931-484-5141
Practice Address - Fax:931-484-5620
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD24627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3076600Medicaid
110074364OtherRAILROAD MEDICARE
TN164200OtherBLUE CROSS
F68572Medicare UPIN
TN164200OtherBLUE CROSS