Provider Demographics
NPI:1124295340
Name:DEMETRIOS PETROVAS M.D. S.C.
Entity type:Organization
Organization Name:DEMETRIOS PETROVAS M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-658-2300
Mailing Address - Street 1:2420 ASBURY RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5902
Mailing Address - Country:US
Mailing Address - Phone:847-400-5485
Mailing Address - Fax:
Practice Address - Street 1:3960 NORTH HARLEM AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2219
Practice Address - Country:US
Practice Address - Phone:773-658-2300
Practice Address - Fax:773-658-2305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042616685261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL987862Medicare PIN