1245882315 NPI number — DR. VANESSA ILIENE PETRAK MD

Table of content: DR. VANESSA ILIENE PETRAK MD (NPI 1245882315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245882315 NPI number — DR. VANESSA ILIENE PETRAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRAK
Provider First Name:
VANESSA
Provider Middle Name:
ILIENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAFF
Provider Other First Name:
VANESSA
Provider Other Middle Name:
ILIENE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245882315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 SHILOH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-6399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-740-3703
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 OGDEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-7222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-978-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2019

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: 207P00000X , with the licence number:  125075211 , 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)





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