Provider Demographics
NPI:1730119074
Name:PETRIE, RUSSELL SEAN (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:SEAN
Last Name:PETRIE
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 1:22 CORPORATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7901
Mailing Address - Country:US
Mailing Address - Phone:949-722-7038
Mailing Address - Fax:949-630-4935
Practice Address - Street 1:22 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7901
Practice Address - Country:US
Practice Address - Phone:949-722-7038
Practice Address - Fax:949-630-4935
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85402207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGU301ZMedicare UPIN
CAF84577Medicare UPIN