Provider Demographics
NPI:1386667269
Name:ANNA PETROV DPM SC
Entity Type:Organization
Organization Name:ANNA PETROV DPM SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-244-6517
Mailing Address - Street 1:4108 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2007
Mailing Address - Country:US
Mailing Address - Phone:773-244-6517
Mailing Address - Fax:773-244-6531
Practice Address - Street 1:4108 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2007
Practice Address - Country:US
Practice Address - Phone:773-244-6517
Practice Address - Fax:773-244-6531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1626058OtherBCBS
ILU77054Medicare UPIN
IL214267Medicare ID - Type Unspecified
IL4474660001Medicare NSC
IL214267Medicare PIN