MEDICARE: PETRA JOSEPH MD

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	207L00000X	Anesthesiology Physician	036-061158	IL
2	208100000X	Physical Medicine & Rehabilitation Physician	036-061158	IL
3	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	036-061158	IL
4	208VP0000X	Pain Medicine Physician	036-061158	IL
5	208VP0014X	Interventional Pain Medicine Physician	036-061158	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	250011935	OTHER	IL	RAILROAD MEDICARE
3	250011936	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679685234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETRA JOSEPH MD

Provider Business Mailing Address
First Line	:	36912 EAGLE WAY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60678-0001
Country	:	US
Telephone Number	:	407-681-2241
Fax Number	:

Provider Business Practice Location Address
First Line	:	1030 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-5467
Country	:	US
Telephone Number	:	312-238-7800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	02/26/2008

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Directions to “ PETRA JOSEPH MD” Practice Location

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