Healthcare Provider Details

I. General information

NPI: 1003270422
Provider Name (Legal Business Name): MICHAEL PETRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6411 VETERANS MEMORIAL PKWY
CRESTWOOD KY
40014-8698
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-241-8611
  • Fax: 502-241-4175
Mailing address:
  • Phone: 502-559-9407
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4220
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: