Provider Demographics
NPI:1922128057
Name:PETRY, MATTHEW ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ALLEN
Last Name:PETRY
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 1:12624 S ROUTE 59 UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5448
Mailing Address - Country:US
Mailing Address - Phone:815-254-1234
Mailing Address - Fax:815-254-2020
Practice Address - Street 1:12624 S ROUTE 59 UNIT 2
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5448
Practice Address - Country:US
Practice Address - Phone:815-254-1234
Practice Address - Fax:815-254-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009285111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232398OtherBCBS PPO