Healthcare Provider Details

I. General information

NPI: 1245351733
Provider Name (Legal Business Name): MYRIA PETROU MBCHB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14995 SHADY GROVE RD
ROCKVILLE MD
20850-8726
US

IV. Provider business mailing address

14995 SHADY GROVE RD
ROCKVILLE MD
20850-8726
US

V. Phone/Fax

Practice location:
  • Phone: 301-217-0500
  • Fax:
Mailing address:
  • Phone: 301-217-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberD0067062
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number4301077422
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301077422
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number62681
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0067062
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: