Provider Demographics
NPI:1407837040
Name:PETROV, ANNA M (DPM)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:M
Last Name:PETROV
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004935213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1626058OtherBC/BS
IL016004935Medicaid
U77054Medicare UPIN
IL214267Medicare PIN
556980Medicare ID - Type Unspecified