Healthcare Provider Details

I. General information

NPI: 1912916818
Provider Name (Legal Business Name): EDWIN L PETRIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 SW 8TH AVE
TOPEKA KS
66606-1535
US

IV. Provider business mailing address

1414 SW 8TH AVE
TOPEKA KS
66606-1535
US

V. Phone/Fax

Practice location:
  • Phone: 785-354-5300
  • Fax: 785-354-5309
Mailing address:
  • Phone: 785-354-5300
  • Fax: 785-354-5309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number04-13299
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number04-13299
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: