Provider Demographics
NPI:1558322289
Name:ANITA L PETTEWAY MD PA
Entity Type:Organization
Organization Name:ANITA L PETTEWAY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-944-8550
Mailing Address - Street 1:909 N. MIAMI BEACH BLVD.
Mailing Address - Street 2:SUITE 503
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162
Mailing Address - Country:US
Mailing Address - Phone:305-944-8887
Mailing Address - Fax:305-944-8440
Practice Address - Street 1:909 N MIAMI BEACH BLVD
Practice Address - Street 2:SUITE 503
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3712
Practice Address - Country:US
Practice Address - Phone:305-944-8887
Practice Address - Fax:305-944-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69729207R00000X
FLPA9102803363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty