Healthcare Provider Details

I. General information

NPI: 1588973341
Provider Name (Legal Business Name): MILAN PETROVIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 10/25/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CHARLOIS BLVD
WINSTON SALEM NC
27103-1508
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-1000
  • Fax: 336-718-1052
Mailing address:
  • Phone: 336-718-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2013-01383
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: