NPIMap

Individual provider Active NPI

Mark H Petry, M.D.

  • Family Medicine Physician
  • Sandstone, MN
National Provider Identifier
1487668034
Registry record updated Jan 3, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
48729 Issued in MN
Practice address
204 Lundorff Dr
Sandstone, MN 55072-5051
Phone
(320) 245-2250
Fax
(320) 245-2555
NPI assigned
Jul 28, 2006
Last updated
Jan 3, 2013By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 3, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 48729 MN Primary

Addresses

Primary practice location

204 Lundorff Dr
Sandstone, MN 55072-5051

Mailing address

204 Lundorff Dr
Sandstone, MN 55072-5051
Phone (320) 245-2250

Other identifiers 4

IdentifierTypeStateIssuer
153H5PEOtherMNBCBSMN
P00440553OtherRR MEDICARE PTAN
602643000MedicaidMN
01-25350OtherMNMEDICA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20060807000141 MN Practitioner - Family Practice 0345243671 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Minnesota Medical School, 2005
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

4570 Cty Hwy 61
Moose Lake, MN 55767-9401
Phone (218) 485-4491

707 Lundorff Dr
Suite 1
Sandstone, MN 55072-5099
Phone (320) 245-2250

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
48729MNMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Pine Medical Center Current Accepting new patients
Pine Medical Center CurrentSince Sep 26, 2016 Accepting new patients
Pine Medical Center CurrentSince Sep 26, 2016 Accepting new patients
Gateway Family Health Clinic, LTD. Family Medicine CurrentSince Nov 15, 2008 Accepting new patients
Gateway Family Health Clinic, LTD. Current Accepting new patients
The Duluth Clinic, LTD. Past Accepting new patients
Gateway Family Health Clinic, LTD. Family Medicine Past Accepting new patients

Locations

204 Lundorff Dr
Sandstone, MN 55072
Phone (320) 245-2250

705 Lundorff Dr
Sandstone, MN 55072
Phone (320) 245-2211

707 Lundorff Dr
#1
Sandstone, MN 55072
Phone (320) 245-2250

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/JDGJBA
  • Direct secure messaging: mark.petry@gfhc.eclinicaldirectplus.com

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Gateway Family Health Clinic, LTD.Sandstone, MN, CCN 243859 Rural health clinic 5% Or Greater Direct Ownership Interest (9.09%)
General Partnership Interest (9.09%)
Corporate Officer (9.09%)
W-2 Managing Employee (9.09%)		 Jun 1, 2010
Jun 1, 2010
Jan 1, 2017
Jun 1, 2010

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 33

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 33

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154044800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1357171200000",
    "number": "1487668034",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "204 LUNDORFF DR",
            "city": "SANDSTONE",
            "state": "MN",
            "postal_code": "550725051",
            "telephone_number": "320-245-2250",
            "fax_number": "320-245-2555"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "204 LUNDORFF DR",
            "city": "SANDSTONE",
            "state": "MN",
            "postal_code": "550725051",
            "telephone_number": "320-245-2250",
            "fax_number": "320-245-2555"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETRY",
        "first_name": "MARK",
        "middle_name": "H",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-28",
        "last_updated": "2013-01-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "48729",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSMN",
            "identifier": "153H5PE",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE PTAN",
            "identifier": "P00440553",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "602643000",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA",
            "identifier": "01-25350",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Sandstone, MN

Sources for this page

Verify at the official NPI Registry.