Healthcare Provider Details

I. General information

NPI: 1265402283
Provider Name (Legal Business Name): KENT A PETRIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BEARD CREEK RD STE 200
EDWARDS CO
81632-6426
US

IV. Provider business mailing address

2700 GILSTRAP CT SUITE 230
GLENWOOD SPRINGS CO
81601-8735
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-2840
  • Fax: 970-945-2893
Mailing address:
  • Phone: 970-945-2840
  • Fax: 970-945-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22520
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: