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Mr. Edward K Petrusch

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NPI Number Detailed Information

Provider Information:

Name: Mr. Edward K Petrusch
Gender: M
Provider License Number If Given: 820A

NPI Information:

NPI: 1386647337
Entity Type
(Individual or Organization):
1-ind
Enumeration Date: 5/23/2005

Last Update Date: 4/11/2013

Provider Business Mailing Address:

Address: 444 COLLETT BRIDGE RD
Alvaton, KY 42122
Phone Number: 2708420433
Fax Number:

Provider Business Practice Location Address:

Address: 444 COLLETT BRIDGE RD
Alvaton, KY 42122
Phone Number: 2708420433
Fax Number:

Provider Taxonomy:

Primary: 367500000X
Secondary (if any):
State: KY

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