Provider Demographics
NPI:1750841623
Name:PETRAK, ROBERT
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PETRAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3806
Mailing Address - Country:US
Mailing Address - Phone:312-942-9694
Mailing Address - Fax:
Practice Address - Street 1:600 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3806
Practice Address - Country:US
Practice Address - Phone:312-942-9694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125075208207R00000X
390200000X
IL036159059207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program