1376644070 NPI number — JOSEPH JOHN PETKEWICH PT

Table of content: JOSEPH JOHN PETKEWICH PT (NPI 1376644070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376644070 NPI number — JOSEPH JOHN PETKEWICH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETKEWICH
Provider First Name:
JOSEPH
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1376644070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
USAMEDDAC BAVARIA
Provider Second Line Business Mailing Address:
CREDENTIALS OFFICE, UNIT 26610
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
011499318897768
Provider Business Mailing Address Fax Number:
011499318897772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USAHC BAVARIA
Provider Second Line Business Practice Location Address:
BAMBERG HC, UNIT 27528
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
011499513008272
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2006

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: 225100000X , with the licence number:  87 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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