Provider Demographics
NPI:1649379447
Name:JOSEPH B. PETELIN, M.D., CHARTERED
Entity Type:Organization
Organization Name:JOSEPH B. PETELIN, M.D., CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF THE PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETELIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-432-5420
Mailing Address - Street 1:9119 W 74TH ST
Mailing Address - Street 2:SUITE 255
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2236
Mailing Address - Country:US
Mailing Address - Phone:913-432-5420
Mailing Address - Fax:913-432-7749
Practice Address - Street 1:9119 W 74TH ST
Practice Address - Street 2:SUITE 255
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2236
Practice Address - Country:US
Practice Address - Phone:913-432-5420
Practice Address - Fax:913-432-7749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS417417208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSC500000Medicare ID - Type Unspecified