Provider Demographics
NPI:1255336764
Name:PETRIE, PATRICIA (DC)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:PETRIE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2956
Mailing Address - Country:US
Mailing Address - Phone:815-288-3614
Mailing Address - Fax:815-285-3525
Practice Address - Street 1:315 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2956
Practice Address - Country:US
Practice Address - Phone:815-288-3614
Practice Address - Fax:815-285-3525
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038004367Medicaid
IL350047766OtherRAILROAD MEDICARE
IL05282006OtherBLUE CROSS BLUE SHIELD
ILT37737Medicare UPIN
T37737Medicare UPIN
IL038004367Medicaid