Provider Demographics
NPI:1376644070
Name:PETKEWICH, JOSEPH JOHN (PT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JOHN
Last Name:PETKEWICH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USAMEDDAC BAVARIA
Mailing Address - Street 2:CREDENTIALS OFFICE, UNIT 26610
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09036
Mailing Address - Country:US
Mailing Address - Phone:01149931-889-7768
Mailing Address - Fax:01149931-889-7772
Practice Address - Street 1:USAHC BAVARIA
Practice Address - Street 2:BAMBERG HC, UNIT 27528
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09139
Practice Address - Country:US
Practice Address - Phone:01149951-300-8272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT87225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN