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NPI Code Detail

MEDICARE: DR. NICHOLAS RYAN PETRE MD

MEDICARE: DR. NICHOLAS RYAN PETRE MD
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
1207Q00000XFamily Medicine Physician125.072248IL

General Provider Information

NPI Number : 1699269308
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. NICHOLAS RYAN PETRE MD
Provider Business Mailing Address
First Line : 306 46TH AVE
Second Line :
City : EAST MOLINE
State : IL
Zip : 61244-4281
Country : US
Telephone Number : 309-796-2329
Fax Number : 309-796-1146
Provider Business Practice Location Address
First Line : 306 46TH AVE
Second Line :
City : EAST MOLINE
State : IL
Zip : 61244-4281
Country : US
Telephone Number : 309-796-2329
Fax Number : 309-796-1146
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2018
Last Update Date : 12/22/2025

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