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General NPI Number Information
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NPI Number | 1245882315
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Entity Type | Individual
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Provider Name | VANESSA ILIENE PETRAK MD
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Gender | Female
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Dates
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Enumeration Date | 07/09/2019
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Last Update Date | 06/27/2022
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Provider Practice Location Address
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Address Line | 2000 OGDEN AVE
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City | AURORA
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State | IL
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Zip | 60504-7222
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Country | US
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Telephone | 630-978-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 6 SHILOH CT
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City | BURR RIDGE
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State | IL
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Zip | 60527-6399
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Country | US
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Telephone | 310-740-3703
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 125075211
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License Number State | IL
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