Active NPI
Mark Edgar Pettay, D.C.
- Chiropractor
- Groveport, OH
National Provider Identifier
1407979313
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Chiropractor
- License
- 1755
- Practice address
- 495 Main St
Suite D
Groveport, OH 43125-1184 - Phone
- (614) 836-7227
- Fax
- (614) 836-3038
- NPI assigned
- Apr 6, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor | 111N00000X | 1755 | OH | Primary |
Addresses
Primary practice location
495 Main St
Suite D
Groveport, OH 43125-1184
Mailing address
495 Main St
Suite D
Groveport, OH 43125-1184
Phone (614) 836-7227
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 311462245 | Other | OH | TAX ID |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1755 | OH | MD | Chiropractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1175817600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1407979313",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "495 MAIN ST",
"address_2": "SUITE D",
"city": "GROVEPORT",
"state": "OH",
"postal_code": "431251184",
"telephone_number": "614-836-7227",
"fax_number": "614-836-3038"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "495 MAIN ST",
"address_2": "SUITE D",
"city": "GROVEPORT",
"state": "OH",
"postal_code": "431251184",
"telephone_number": "614-836-7227",
"fax_number": "614-836-3038"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETTAY",
"first_name": "MARK",
"middle_name": "EDGAR",
"name_prefix": "Dr.",
"credential": "D.C.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-04-06",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "111N00000X",
"taxonomy_group": "",
"desc": "Chiropractor",
"state": "OH",
"license": "1755",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TAX ID",
"identifier": "311462245",
"state": "OH"
}
],
"endpoints": [],
"other_names": []
}Other providers in Groveport, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.