Provider Demographics
NPI:1821196205
Name:PETTAY, STEPHEN RAY (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RAY
Last Name:PETTAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-1869
Mailing Address - Country:US
Mailing Address - Phone:614-451-0472
Mailing Address - Fax:614-451-0882
Practice Address - Street 1:1875 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-1869
Practice Address - Country:US
Practice Address - Phone:614-451-0472
Practice Address - Fax:614-451-0882
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH976111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPE0538871Medicare PIN