Healthcare Provider Details

I. General information

NPI: 1629005160
Provider Name (Legal Business Name): MICHAEL R PETERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N HURON RIVER DR STE 100
YPSILANTI MI
48197
US

IV. Provider business mailing address

39650 ORCHARD HILL PL STE 200
NOVI MI
48375-5391
US

V. Phone/Fax

Practice location:
  • Phone: 734-572-1200
  • Fax: 734-572-9760
Mailing address:
  • Phone: 248-319-0161
  • Fax: 248-319-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35-06-3107
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number4301406847
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: