Healthcare Provider Details

I. General information

NPI: 1417545773
Provider Name (Legal Business Name): PETOSKEY PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 N DIVISION RD
PETOSKEY MI
49770-9416
US

IV. Provider business mailing address

345 N DIVISION RD
PETOSKEY MI
49770-9416
US

V. Phone/Fax

Practice location:
  • Phone: 231-347-8382
  • Fax: 231-347-6628
Mailing address:
  • Phone: 231-347-8382
  • Fax: 231-347-6628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARY J HANDWERK
Title or Position: INSURANCE BILLER
Credential:
Phone: 231-347-8382