Healthcare Provider Details

I. General information

NPI: 1730145574
Provider Name (Legal Business Name): PETOSKEY SURGEONS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 MONROE ST
PETOSKEY MI
49770-2266
US

IV. Provider business mailing address

521 MONROE ST
PETOSKEY MI
49770-2266
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-1900
  • Fax: 231-348-0984
Mailing address:
  • Phone: 231-487-1900
  • Fax: 231-348-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN M. MARKHAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 231-487-1900