Provider Demographics
NPI:1306881198
Name:PETROVICH, LAWRENCE J (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:PETROVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HOSPITAL DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1030
Mailing Address - Country:US
Mailing Address - Phone:207-363-6136
Mailing Address - Fax:207-363-4863
Practice Address - Street 1:12 HOSPITAL DR
Practice Address - Street 2:SUITE 9
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1030
Practice Address - Country:US
Practice Address - Phone:207-363-6136
Practice Address - Fax:207-363-4863
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME8487207RC0000X
NH6006207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME322840099Medicaid
NH81113078Medicaid
NHNH3078Medicare PIN
B85985Medicare UPIN
ME322840099Medicaid