Healthcare Provider Details

I. General information

NPI: 1225167349
Provider Name (Legal Business Name): PAUL PETRE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24362 RENSSELAER ST
OAK PARK MI
48237-1781
US

IV. Provider business mailing address

24362 RENSSELAER ST
OAK PARK MI
48237-1781
US

V. Phone/Fax

Practice location:
  • Phone: 313-673-9145
  • Fax:
Mailing address:
  • Phone: 313-673-9145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301078751
License Number StateMI

VIII. Authorized Official

Name: DR. PAUL M PETRE
Title or Position: OWNER
Credential: MD
Phone: 313-673-9145