Healthcare Provider Details

I. General information

NPI: 1497105431
Provider Name (Legal Business Name): SARAH PETTIBONE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAMPUS DR
HANCOCK MI
49930-1452
US

IV. Provider business mailing address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1060
  • Fax: 906-372-3230
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301500331
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: