Provider Demographics
NPI:1477568863
Name:PETROFF, ROMAN (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:PETROFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 SOM CENTER RD STE 230
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44143-2362
Mailing Address - Country:US
Mailing Address - Phone:440-461-6477
Mailing Address - Fax:440-461-1017
Practice Address - Street 1:730 SOM CENTER RD STE 230
Practice Address - Street 2:
Practice Address - City:MAYFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44143-2362
Practice Address - Country:US
Practice Address - Phone:440-461-6477
Practice Address - Fax:440-461-1017
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047914207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH110216615OtherRAILROAD
OH0512903Medicaid
OHPE0528295Medicare ID - Type Unspecified
OH110216615OtherRAILROAD