Provider Demographics
NPI:1497702641
Name:PETRACK, EMORY MARK (MD)
Entity Type:Individual
Prefix:
First Name:EMORY
Middle Name:MARK
Last Name:PETRACK
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 1:2696 W SAINT JAMES PKWY
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18101 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5612
Practice Address - Country:US
Practice Address - Phone:216-476-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063327207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH942460636312OtherCARESOURCE
OH0887189Medicaid
OH0887189Medicaid