Individual
CHANNING PETRAK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
DEPT OF PEDIATRICS, 320 E ARMSTRONG, PEORIA, IL 61603
(309) 624-9587
Mailing address
1 ILLINI DR, PEORIA, IL 61605-2576
(309) 671-8503
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036108511
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036108511
—
IL
01
—
07215036
BCBS
IL
01
—
639810
MEDICARE PTAN
IL
01
—
IL01CN
JOHN DEERE
IL
Enumeration date
03/16/2006
Last updated
07/22/2013
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