Healthcare Provider Details

I. General information

NPI: 1023014305
Provider Name (Legal Business Name): JERRY D PETERIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S HILLSIDE ST
WICHITA KS
67211-2129
US

IV. Provider business mailing address

310 S HILLSIDE ST
WICHITA KS
67211-2129
US

V. Phone/Fax

Practice location:
  • Phone: 316-264-3505
  • Fax: 316-264-0908
Mailing address:
  • Phone: 316-264-3505
  • Fax: 316-264-0908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0416578
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: