Provider Demographics
NPI:1255352050
Name:PETRUSKA, GEORGE KENNETH (DC, DACRB)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:KENNETH
Last Name:PETRUSKA
Suffix:
Gender:M
Credentials:DC, DACRB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 GERYVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:PENNSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18073-2306
Mailing Address - Country:US
Mailing Address - Phone:215-679-3419
Mailing Address - Fax:215-679-8866
Practice Address - Street 1:2791 GERYVILLE PIKE
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073-2306
Practice Address - Country:US
Practice Address - Phone:215-679-3419
Practice Address - Fax:215-679-8866
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002109L111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT72877Medicare UPIN
PA927706Medicare ID - Type Unspecified