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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 |