Healthcare Provider Details

I. General information

NPI: 1336234491
Provider Name (Legal Business Name): PETOSKEY CHILD HEALTH ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 MITCHELL PARK DR SUITE A
PETOSKEY MI
49770-8965
US

IV. Provider business mailing address

2390 MITCHELL PARK DR SUITE A
PETOSKEY MI
49770-8965
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-2250
  • Fax: 231-348-7972
Mailing address:
  • Phone: 231-487-2250
  • Fax: 231-348-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN ROBERT SEAGREN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 231-487-2250