Healthcare Provider Details

I. General information

NPI: 1659401958
Provider Name (Legal Business Name): MICHAEL PETTEI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269-01 76TH AVENUE LIJMC - DEPT OF PEDIATRICS
NEW HYDE PARK NY
11040
US

IV. Provider business mailing address

269-01 76TH AVENUE LIJMC - DEPT OF PEDIATRICS
NEW HYDE PARK NY
11040
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-3430
  • Fax:
Mailing address:
  • Phone: 718-470-3430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number147979
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: