Provider Demographics
NPI:1679683148
Name:PETTIGREW, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:PETTIGREW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 N MERIDIAN ST STE 114
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1208
Mailing Address - Country:US
Mailing Address - Phone:317-274-4402
Mailing Address - Fax:317-274-5168
Practice Address - Street 1:557 PIT ROAD
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112
Practice Address - Country:US
Practice Address - Phone:317-885-2700
Practice Address - Fax:317-988-5523
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038748A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100120580Medicaid
INFO2198Medicare UPIN