Provider Demographics
NPI:1265590087
Name:PETREY JR., JOHN S (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:PETREY JR.
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 1:700 E SPRING ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2926
Mailing Address - Country:US
Mailing Address - Phone:812-945-7536
Mailing Address - Fax:812-945-7542
Practice Address - Street 1:700 E SPRING ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2926
Practice Address - Country:US
Practice Address - Phone:812-945-7536
Practice Address - Fax:812-945-7542
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043127A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100460250AMedicaid
IN61-1091357OtherTAX ID
INF90192Medicare UPIN
IN61-1091357OtherTAX ID