NPIMap

Individual provider Active NPI

Nicholas Petrochko Jr., M.D.

  • Surgery Physician
  • Clackamas, OR
National Provider Identifier
1356352579
Registry record updated Feb 20, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
MD010073 Issued in TN
Practice address
9900 SE Sunnyside Rd
Clackamas, OR 97015-9777
Phone
(503) 652-2880
Fax
(503) 571-8984
NPI assigned
Aug 11, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 20, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery Physician 208600000X MD010073 TN Primary

Addresses

Primary practice location

9900 SE Sunnyside Rd
Clackamas, OR 97015-9777

Mailing address

9900 SE Sunnyside Rd
Clackamas, OR 97015-9777
Phone (503) 652-2880

Other identifiers 3

IdentifierTypeStateIssuer
2000698OtherTNBLUE CROSS OF TENNESSEE
3013285MedicaidTN
4535569OtherTNAETNA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled
HHS exclusion list flag
CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD010073TNMDSurgery Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Cumberland Healthcare Group, PLLC Surgery Past Accepting new patients
West Florida Specialty Physicians LLC Past Accepting new patients
Pecos Valley of New Mexico, LLC Past Accepting new patients

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155254400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1203465600000",
    "number": "1356352579",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9900 SE SUNNYSIDE RD",
            "city": "CLACKAMAS",
            "state": "OR",
            "postal_code": "970159777",
            "telephone_number": "503-652-2880",
            "fax_number": "503-571-8984"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9900 SE SUNNYSIDE RD",
            "city": "CLACKAMAS",
            "state": "OR",
            "postal_code": "970159777",
            "telephone_number": "503-652-2880",
            "fax_number": "503-571-8984"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETROCHKO",
        "first_name": "NICHOLAS",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-11",
        "last_updated": "2008-02-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "TN",
            "license": "MD010073",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF TENNESSEE",
            "identifier": "2000698",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3013285",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "4535569",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Clackamas, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 20, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.