Provider Demographics
NPI:1861673881
Name:PETREY, WILKES BANKS (MD)
Entity Type:Individual
Prefix:
First Name:WILKES
Middle Name:BANKS
Last Name:PETREY
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 1:4517 SOUTHLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3280
Mailing Address - Country:US
Mailing Address - Phone:205-985-4111
Mailing Address - Fax:205-985-4326
Practice Address - Street 1:4517 SOUTHLAKE PKWY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3280
Practice Address - Country:US
Practice Address - Phone:205-985-4111
Practice Address - Fax:205-985-4326
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL269082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-03855OtherBLUE CROSS
AL511-09829OtherBLUE CROSS
AL511-56302OtherBLUE CROSS
AL117959Medicaid
AL122777Medicaid
AL511-03857OtherBLUE CROSS
AL117963Medicaid
AL117962Medicaid
VA1861673881Medicaid
AL511-03856OtherBLUE CROSS
AL102I300312Medicare PIN
AL511-03857OtherBLUE CROSS