1104955277 NPI number — ELIZABETH PETROPOULOS PT

Table of content: ELIZABETH PETROPOULOS PT (NPI 1104955277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104955277 NPI number — ELIZABETH PETROPOULOS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETROPOULOS
Provider First Name:
ELIZABETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104955277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6N406 BAKER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ITASCA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60143-1936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-917-5210
Provider Business Mailing Address Fax Number:
847-481-0232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6N406 BAKER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITASCA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60143-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-917-5210
Provider Business Practice Location Address Fax Number:
847-481-0232
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251P0200X , with the licence number:  070003531 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0007153719 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1871690446 . This is a "NPI TYPE 2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4532188 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com