Provider Demographics
NPI:1598832032
Name:PETTERCHAK, JAMES A (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:PETTERCHAK
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 1:3015 N. BALLAS
Mailing Address - Street 2:DEPT OF PATHOLOGY
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-996-5551
Mailing Address - Fax:314-996-5551
Practice Address - Street 1:3015 N. BALLAS
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-996-5551
Practice Address - Fax:314-996-5551
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101883207ZF0201X, 207ZP0101X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1598832032Medicaid
MO1598832032Medicaid
MO116980001Medicare PIN