1992996383 NPI number — DR. ELLEN RENEE PETROCZKY O.D.

Table of content: DR. ELLEN RENEE PETROCZKY O.D. (NPI 1992996383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992996383 NPI number — DR. ELLEN RENEE PETROCZKY O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETROCZKY
Provider First Name:
ELLEN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1992996383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
178 LONGFORD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60120-4688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-291-7647
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
363 S RANDALL RD
Provider Second Line Business Practice Location Address:
ELGIN FAMILY EYE CARE
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60123-5526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-888-1555
Provider Business Practice Location Address Fax Number:
847-888-2508
Provider Enumeration Date:
08/09/2007

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: 152W00000X , with the licence number:  046.009976 , 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)





Copyright © 2007-2025 www.npivalidator.com