Provider Demographics
NPI:1700638954
Name:PETTEY, BRIAN MATTHEW
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MATTHEW
Last Name:PETTEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 HIDEOUT LN
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-9001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1110
Practice Address - Country:US
Practice Address - Phone:847-318-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program