Channing Petrak, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

036108511 Issued in IL

Practice address

Dept of Pediatrics
320 E Armstrong
Peoria, IL 61603

Phone

(309) 624-9587

NPI assigned

Mar 16, 2006

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

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

• The Board of Trustees of the University of Illinois

  • Anatomic Pathology Physician
  • Chicago, IL
  • NPI 1386863819
  Medicare reassignment NPD
• Board of Trustees of the University of Illinois

  • Pediatrics Physician
  • Peoria, IL
  • NPI 1467425322
  NPD
• The Board of Trustees of the University of Illinois

  • Occupational Medicine Physician
  • Chicago, IL
  • NPI 1043727571
  NPD
• University of Illinois

  • Pediatric Neurodevelopmental Disabilities Physician
  • Peoria, IL
  • NPI 1174596225
  NPD (past)
• University of Illinois

  • Pediatric Critical Care Medicine Physician
  • Peoria, IL
  • NPI 1205807187
  NPD (past)
• University of Illinois

  • Psychiatry Physician
  • Peoria, IL
  • NPI 1245203280
  NPD (past)
• University of Illinois

  • Internal Medicine Physician
  • Peoria, IL
  • NPI 1255301909
  NPD (past)
• University of Illinois

  • Pediatric Hematology & Oncology Physician
  • Peoria, IL
  • NPI 1568433050
  NPD (past)
• University of Illinois

  • Developmental - Behavioral Pediatrics Physician
  • Peoria, IL
  • NPI 1619948411
  NPD (past)
• University of Illinois

  • Obstetrics & Gynecology Physician
  • Peoria, IL
  • NPI 1962475996
  NPD (past)

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

{
    "created_epoch": "1142467200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1374451200000",
    "number": "1952370538",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 ILLINI DR",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616052576",
            "telephone_number": "309-671-8503"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "DEPT OF PEDIATRICS",
            "address_2": "320 E ARMSTRONG",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "61603",
            "telephone_number": "309-624-9587"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETRAK",
        "first_name": "CHANNING",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-03-16",
        "last_updated": "2013-07-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "IL",
            "license": "036108511",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036108511",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "639810",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "07215036",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "JOHN DEERE",
            "identifier": "IL01CN",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jaimie M Peterson
• Sarah Peterson
• Thitapa Petlerkwong, DO
• Collin Petoskey, D.D.S.
• Lauren M Petoskey, PA-C
• Cindy Pettit, DNP, FNP-BC
• Nicholas Peyton, ATC
• Maci Pfeffer
• Eric L. Pfeiffer, APN
• Benjamin R Pflederer, MD

• Pediatrics Physician in Peoria, IL
• Providers in Peoria, IL by specialty
• Pediatrics Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.