Provider Demographics
NPI:1851313019
Name:PETRICH, RUDOLPH J (DPM)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:J
Last Name:PETRICH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-2126
Mailing Address - Country:US
Mailing Address - Phone:630-766-8720
Mailing Address - Fax:630-766-9228
Practice Address - Street 1:14 S ADDISON ST
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-2126
Practice Address - Country:US
Practice Address - Phone:630-766-8720
Practice Address - Fax:630-766-9228
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003067213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003067Medicaid
IL648613Medicare Oscar/Certification
IL016003067Medicaid