Provider Demographics
NPI:1073870689
Name:PETRUSICH, JAMES PATRICK (DOCTOR OF AUDIOLOGY)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:PATRICK
Last Name:PETRUSICH
Suffix:
Gender:M
Credentials:DOCTOR OF AUDIOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 E 19TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3385
Mailing Address - Country:US
Mailing Address - Phone:541-298-8676
Mailing Address - Fax:541-298-7746
Practice Address - Street 1:1815 E 19TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3385
Practice Address - Country:US
Practice Address - Phone:541-298-8676
Practice Address - Fax:541-298-7746
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23599231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01627946OtherRR MEDICARE
FLIM673ZMedicare PIN