1548698368 NPI number — DR BARBARA LYNN PETKOVIC DPM LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548698368 NPI number — DR BARBARA LYNN PETKOVIC DPM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR BARBARA LYNN PETKOVIC DPM LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1548698368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH ROYALTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44133-0501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-885-2130
Provider Business Mailing Address Fax Number:
440-848-8406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10631 SHERWOOD TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH ROYALTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44133-1979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-885-2130
Provider Business Practice Location Address Fax Number:
440-848-8406
Provider Enumeration Date:
10/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PETKOVIC
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
440-885-2130

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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