=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558322289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANITA L PETTEWAY MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 NW 168TH ST STE 301
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-6051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-944-8887
-----------------------------------------------------
Fax | 877-488-9590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 NW 168TH ST STE 301
-----------------------------------------------------
City | NORTH MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-6051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-944-8887
-----------------------------------------------------
Fax | 877-488-9590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MRS. DORENDA WASHINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-944-8887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9102803
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME69729
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------