Healthcare Provider Details

I. General information

NPI: 1548261944
Provider Name (Legal Business Name): MARK E PETRIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13151 MAGISTERIAL DR STE 200
LOUISVILLE KY
40223-4103
US

IV. Provider business mailing address

13151 MAGISTERIAL DR STE 200
LOUISVILLE KY
40223-4103
US

V. Phone/Fax

Practice location:
  • Phone: 502-587-1236
  • Fax: 502-587-0126
Mailing address:
  • Phone: 502-587-1236
  • Fax: 502-587-0126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number26506
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: