Healthcare Provider Details

I. General information

NPI: 1063498830
Provider Name (Legal Business Name): MR. MICHAEL KENNETH PETROSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 2ND ST SW SUITE 5314
WASHINGTON DC
20593-0002
US

IV. Provider business mailing address

152 W KLASKANINE AVE
ASTORIA OR
97103-5759
US

V. Phone/Fax

Practice location:
  • Phone: 503-861-6155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: