1013253384 NPI number — ELENA PETRUSEVSKA PA-C

Table of content: ELENA PETRUSEVSKA PA-C (NPI 1013253384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013253384 NPI number — ELENA PETRUSEVSKA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRUSEVSKA
Provider First Name:
ELENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1013253384
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3276
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47731-3276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-473-0181
Provider Business Mailing Address Fax Number:
812-473-5822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 W IRVING PARK RD
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-975-3269
Provider Business Practice Location Address Fax Number:
773-975-3270
Provider Enumeration Date:
12/14/2012

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: 363AM0700X , with the licence number:  085-004506 , 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: 085-004506 . This is a "STATE OF IL LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com