Individual
RUSSELL PETTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
HIGHWAY 281 NORTH, CANDO, ND 58324-0688
(701) 968-2541
(701) 968-2574
Mailing address
PO BOX 688, CANDO, ND 58324-0688
(701) 968-2541
(701) 968-2574
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
3895
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
12622
—
ND
01
—
21510
BCBS PROVIDER #
ND
01
—
24029
BCBS PROVIDER #
ND
Enumeration date
07/12/2006
Last updated
07/09/2007
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