Healthcare Provider Details

I. General information

NPI: 1114128808
Provider Name (Legal Business Name): MATTHEW SHANE PETRIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 WASHINGTON RD SUITE 203
MC MURRAY PA
15317-3279
US

IV. Provider business mailing address

3055 WASHINGTON RD SUITE 203
MC MURRAY PA
15317-3279
US

V. Phone/Fax

Practice location:
  • Phone: 724-260-5424
  • Fax: 724-260-5425
Mailing address:
  • Phone: 724-260-5424
  • Fax: 724-260-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberD72126
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD438908
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD438908
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD72126
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier102851711-0002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: