Provider Demographics
NPI:1679685234
Name:JOSEPH, PETRA (MD)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PETRA
Other - Middle Name:
Other - Last Name:NOVOTNY-JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:36912 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-0001
Mailing Address - Country:US
Mailing Address - Phone:407-681-2241
Mailing Address - Fax:
Practice Address - Street 1:1030 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-5467
Practice Address - Country:US
Practice Address - Phone:312-238-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-061158207L00000X, 208100000X, 2081P2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL250011935OtherRAILROAD MEDICARE
IL036061158Medicaid
IL250011936OtherRAILROAD MEDICARE
C44941Medicare UPIN
IL036061158Medicaid
ILL77482Medicare ID - Type UnspecifiedDUPAGE COUNTY PIN NUMBER
IL250011936OtherRAILROAD MEDICARE