Individual
GREGORY J PETTAWAY II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
615 N MICHIGAN ST, SOUTH BEND, IN 46601-1033
(574) 647-1000
Mailing address
615 N MICHIGAN ST, SOUTH BEND, IN 46601-1033
(574) 647-1817
(574) 647-3962
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
01078046A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300001115
—
IN
01
—
941030008
MEDICARE PTAN
IN
Enumeration date
04/30/2014
Last updated
07/21/2022
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