MEDICARE: PETER S. PETROVAS D.C. L.T.D.

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	111N00000X	Chiropractor	111N00000X	IL

General Provider Information

NPI Number	:	1346471257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER S. PETROVAS D.C. L.T.D.

Provider Business Mailing Address
First Line	:	5962 N LINCOLN AVE
Second Line	:	SUITE 12
City	:	CHICAGO
State	:	IL
Zip	:	60659-3711
Country	:	US
Telephone Number	:	773-989-4305
Fax Number	:	773-989-7450

Provider Business Practice Location Address
First Line	:	5962 N LINCOLN AVE
Second Line	:	SUITE 12
City	:	CHICAGO
State	:	IL
Zip	:	60659-3711
Country	:	US
Telephone Number	:	773-989-4305
Fax Number	:	773-989-7450

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PETER STEVEN PETROVAS
Credential	:	D.C.
Telephone Number	:	17739894305

Provider Enumeration Date	:	07/28/2009
Last Update Date	:	07/28/2009

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