MEDICARE: THOMAS C. PETRIE, C.D.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service	003560	NY

General Provider Information

NPI Number	:	1396138871
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS C. PETRIE, C.D.N.

Provider Business Mailing Address
First Line	:	110 BROOKLINE RD
Second Line	:	APT. B-11
City	:	BALLSTON SPA
State	:	NY
Zip	:	12020-3527
Country	:	US
Telephone Number	:	518-879-5877
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 WASHINGTON ST
Second Line	:
City	:	BALLSTON SPA
State	:	NY
Zip	:	12020-1761
Country	:	US
Telephone Number	:	518-879-5877
Fax Number	:

Authorized Official
Title or Position	:	NUTRITIONIST
Name	:	MR. THOMAS CHARLES PETRIE
Credential	:	C.D.N.
Telephone Number	:	518-490-1720

Provider Enumeration Date	:	03/09/2015
Last Update Date	:	03/09/2015

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