Provider Demographics
NPI:1396743605
Name:PETRICK, MARIA M (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:M
Last Name:PETRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:M
Other - Last Name:PALMIERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 STONY POINT RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4120
Mailing Address - Country:US
Mailing Address - Phone:707-525-0211
Mailing Address - Fax:707-525-0491
Practice Address - Street 1:130 STONY POINT RD
Practice Address - Street 2:SUITE E
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4120
Practice Address - Country:US
Practice Address - Phone:707-525-0211
Practice Address - Fax:707-525-0491
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40808207K00000X
IN01063403A207K00000X
CAC132754207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000514027OtherANTHEM PIN
HKRAA3F00OtherHIN NUMBER
KYP00411953OtherRAILROAD MEDICARE
ZZZ95243ZOtherMEDICARE PTAN
IN200855600Medicaid
KY7100013590Medicaid
KY50015240OtherPASSPORT
CAGR0061440Medicaid
CAGR0061440Medicaid
KY50015240OtherPASSPORT
KY000000514027OtherANTHEM PIN
IN200855600Medicaid