Provider Demographics
NPI:1497304604
Name:PETRONOVICH, NICHOLAS J (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:PETRONOVICH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E ERIE ST STE 13-205
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2987
Mailing Address - Country:US
Mailing Address - Phone:312-695-8143
Mailing Address - Fax:312-695-4075
Practice Address - Street 1:259 E ERIE ST STE 13-205
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2987
Practice Address - Country:US
Practice Address - Phone:312-695-8143
Practice Address - Fax:312-695-4075
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024780225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist