MEDICARE: DR. COURTNEY KATRIL PETTIFORD M.D.

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	208600000X	Surgery Physician	64715	GA
2	208600000X	Surgery Physician	24518	WV

General Provider Information

NPI Number	:	1770700163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COURTNEY KATRIL PETTIFORD M.D.

Provider Business Mailing Address
First Line	:	122 GEORGE ST.
Second Line	:
City	:	BECKLEY
State	:	WV
Zip	:	25801-2641
Country	:	US
Telephone Number	:	304-250-0382
Fax Number	:	304-250-0383

Provider Business Practice Location Address
First Line	:	122 GEORGE ST
Second Line	:
City	:	BECKLEY
State	:	WV
Zip	:	25801-2641
Country	:	US
Telephone Number	:	304-250-0382
Fax Number	:	304-250-0383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	04/26/2012

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