Healthcare Provider Details

I. General information

NPI: 1205868908
Provider Name (Legal Business Name): PETER STEPHEN NOVACK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 HILL ST
BUCYRUS OH
44820-1566
US

IV. Provider business mailing address

700 N COLUMBUS ST
CRESTLINE OH
44827-1455
US

V. Phone/Fax

Practice location:
  • Phone: 419-563-3247
  • Fax: 419-563-3248
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number34.005240
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34005240
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number34.005240
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: