Provider Demographics
NPI:1306825682
Name:PETROVAS, PETER S (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
Last Name:PETROVAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5962 N LINCOLN AVE
Mailing Address - Street 2:STE 12
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-989-4305
Mailing Address - Fax:773-989-7450
Practice Address - Street 1:5962 N LINCOLN AVE
Practice Address - Street 2:STE 12
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659
Practice Address - Country:US
Practice Address - Phone:773-989-4305
Practice Address - Fax:773-989-7450
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1682631OtherBLUE CROSS BLUE SHIELD