Provider Demographics
NPI:1861680316
Name:PETKOVICH ORTHOPEDIC AND SPINE CARE LLC
Entity Type:Organization
Organization Name:PETKOVICH ORTHOPEDIC AND SPINE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:OGDEN
Authorized Official - Last Name:PETKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-432-6500
Mailing Address - Street 1:2821 N BALLAS RD
Mailing Address - Street 2:SUITE C 70
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2321
Mailing Address - Country:US
Mailing Address - Phone:314-432-6500
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD
Practice Address - Street 2:SUITE C 70
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2321
Practice Address - Country:US
Practice Address - Phone:314-432-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5882207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA09883Medicare UPIN
6024460001Medicare NSC