Provider Demographics
NPI:1265402283
Name:PETRIE, KENT A (MD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:A
Last Name:PETRIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 GILSTRAP CT
Mailing Address - Street 2:SUITE 230
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-8735
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:970-945-2893
Practice Address - Street 1:320 BEARD CREEK RD STE 200
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-6426
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000104567Medicaid
CO01225200Medicaid
CO301587Medicare PIN
E47721Medicare UPIN