Basic Information
| Provider Information | |||||||||
| NPI: | 1205868908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOVACK | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 N COLUMBUS ST | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448271455 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1593 OLENTANGY RD | ||||||||
| Address2: | |||||||||
| City: | GALION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448339762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194687785 | ||||||||
| FaxNumber: | 4194687295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | 34.005240 | OH | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 208600000X | 34005240 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0824531 | 05 | OH | MEDICAID |