Healthcare Provider Details

I. General information

NPI: 1609844208
Provider Name (Legal Business Name): TIMOTHY PETROSKY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26850 PROVIDENCE PKWY SUITE 260
NOVI MI
48374
US

IV. Provider business mailing address

61 COMMERCE AVE SW
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 248-735-8272
  • Fax: 248-735-7276
Mailing address:
  • Phone: 616-940-0660
  • Fax: 616-940-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003397
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: