MEDICARE: SUSAN VEATCH PETTIS

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	225100000X	Physical Therapist		AK

General Provider Information

NPI Number	:	1972735272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN VEATCH PETTIS

Provider Business Mailing Address
First Line	:	PO BOX 241769
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99524-1769
Country	:	US
Telephone Number	:	907-770-2301
Fax Number	:	907-770-2325

Provider Business Practice Location Address
First Line	:	11551 TANGLEWOOD LAKES CIR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99516-1304
Country	:	US
Telephone Number	:	907-562-7745
Fax Number	:	907-562-7808

Authorized Official
Title or Position	:	BILLING AGENT
Name	:	JOSEPH E BEATY
Credential	:
Telephone Number	:	907-770-2301

Provider Enumeration Date	:	08/20/2009
Last Update Date	:	08/20/2009

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Directions to “SUSAN VEATCH PETTIS ” Practice Location

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