Provider Demographics
NPI:1770727232
Name:PETRIE GERIATRIC HEALTHCARE INC
Entity type:Organization
Organization Name:PETRIE GERIATRIC HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:850-516-1919
Mailing Address - Street 1:P.O. BOX 37277
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526
Mailing Address - Country:US
Mailing Address - Phone:850-623-2948
Mailing Address - Fax:
Practice Address - Street 1:1286 FERNANDO CIR
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-5737
Practice Address - Country:US
Practice Address - Phone:850-516-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1222292363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00A39OtherBLUE CROSS BLUE SHIELD
FL306540500Medicaid
FLBZ791Medicare PIN