Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | 016004935 | IL |
N | 222Z00000X | Podiatrist | 016004935 | IL |
Y | 213ES0131X | Foot Surgery | 016004935 | IL |
NPI | 1407837040 |
---|---|
Provider Name | Anna M Petrov |
First Address | Chicago, IL 60613-2007 |
Second Address | Chicago, IL 60613-2007 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2005 |
Last Update Date | 13/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
016004935 | (05) | IL |
1626058 | BC/BS (01) | |
U77054 | (02) |