Healthcare Provider Details

I. General information

NPI: 1134125164
Provider Name (Legal Business Name): ANNE M PETRE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNE M PENAVA

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 46TH AVE
EAST MOLINE IL
61244-4281
US

IV. Provider business mailing address

306 46TH AVE
EAST MOLINE IL
61244-4281
US

V. Phone/Fax

Practice location:
  • Phone: 309-796-2329
  • Fax: 309-796-1146
Mailing address:
  • Phone: 309-796-2329
  • Fax: 309-796-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-091695
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036091695
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: