Provider Demographics
NPI:1376539692
Name:PETRAK, RUSSELL M (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:M
Last Name:PETRAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-654-4253
Practice Address - Street 1:901 MCCLINTOCK DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0872
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-654-4253
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-063551207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200856780Medicaid
IL036-063-551Medicaid
AZZ158638OtherMEDICARE PIN
IA0420281Medicaid
ILL58757Medicare PIN
IN200856780Medicaid
ILL32315Medicare PIN
ILL52057Medicare PIN
IA0420281Medicaid