Provider Demographics
NPI:1770574147
Name:PETRENKO, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PETRENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-9472
Mailing Address - Country:US
Mailing Address - Phone:606-348-3365
Mailing Address - Fax:606-348-8496
Practice Address - Street 1:1 S CREEK DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-9472
Practice Address - Country:US
Practice Address - Phone:606-348-3365
Practice Address - Fax:606-348-8496
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64018799Medicaid
KY64018799Medicaid
KY1282118Medicare UPIN