Provider Demographics
NPI:1821234329
Name:BEVERLEY A PETRIE MD INC
Entity Type:Organization
Organization Name:BEVERLEY A PETRIE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-539-2630
Mailing Address - Street 1:3400 LOMITA BLVD
Mailing Address - Street 2:SUITE # 500
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4909
Mailing Address - Country:US
Mailing Address - Phone:310-539-2630
Mailing Address - Fax:310-539-9785
Practice Address - Street 1:3400 LOMITA BLVD
Practice Address - Street 2:SUITE # 500
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4909
Practice Address - Country:US
Practice Address - Phone:310-539-2630
Practice Address - Fax:310-539-9785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55817208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA55817Medicare PIN