MEDICARE: MR. EDWARD K PETRUSCH CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	820A	KY

General Provider Information

NPI Number	:	1386647337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDWARD K PETRUSCH CRNA

Provider Business Mailing Address
First Line	:	444 COLLETT BRIDGE RD
Second Line	:
City	:	ALVATON
State	:	KY
Zip	:	42122-9675
Country	:	US
Telephone Number	:	270-842-0433
Fax Number	:

Provider Business Practice Location Address
First Line	:	444 COLLETT BRIDGE RD
Second Line	:
City	:	ALVATON
State	:	KY
Zip	:	42122-9675
Country	:	US
Telephone Number	:	270-842-0433
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	04/11/2013

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