Provider Demographics
NPI:1912916818
Name:PETRIK, EDWIN L (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:L
Last Name:PETRIK
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 1:1414 SW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1535
Mailing Address - Country:US
Mailing Address - Phone:785-354-5300
Mailing Address - Fax:785-354-5309
Practice Address - Street 1:1414 SW 8TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1535
Practice Address - Country:US
Practice Address - Phone:785-354-5300
Practice Address - Fax:785-354-5309
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-13299207RX0202X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS067031OtherMEDICARE PTAN
KS100178240AMedicaid
KS100178240AMedicaid