Provider Demographics
NPI:1447340302
Name:PETRIE, BRIAN RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:RICHARD
Last Name:PETRIE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 SOUTH ST W
Mailing Address - Street 2:UNIT 2
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-5305
Mailing Address - Country:US
Mailing Address - Phone:508-821-4049
Mailing Address - Fax:508-821-2526
Practice Address - Street 1:575 SOUTH ST W
Practice Address - Street 2:UNIT 2
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5305
Practice Address - Country:US
Practice Address - Phone:508-821-4049
Practice Address - Fax:508-821-2526
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1824111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY36303OtherBC/BS OF MA PROVIDER NO
MA1601580Medicaid
MA335503OtherTUFTS OUT OF NETWORK ID
MA401417OtherBLUE CHIP RI ID NO
MAZY39272OtherBC/BS MA GROUP ID NO
MA4981-2OtherBC/BS RI PROVIDER NO
MAZY39272OtherBC/BS MA GROUP ID NO