Basic Information
| Provider Information | |||||||||
| NPI: | 1023087715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRYK | ||||||||
| FirstName: | ANDRZEJ | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1580 BEAM AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517797978 | ||||||||
| FaxNumber: | 6517797656 | ||||||||
| Practice Location | |||||||||
| Address1: | 1580 BEAM AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517797978 | ||||||||
| FaxNumber: | 6517797656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 10/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 43012 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 275S6PE | 01 | MN | BLUE CROSS BLUE SHIELD MN | OTHER | 403933500 | 05 | MN | MEDICAID | 01025768 | 01 | MN | PREFERRED ONE | OTHER | 34051900 | 05 | WI | MEDICAID | 3600229 | 01 | MN | MEDICA | OTHER | 1161828 | 01 | MN | AMERICA'S PPO | OTHER | 151274 | 01 | MN | UCARE MN | OTHER | HP31687 | 01 | MN | HEALTHPARTNERS | OTHER |