=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629005160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL R PETERSEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 08/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 N HURON RIVER DR STE 100
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-572-1200
-----------------------------------------------------
Fax | 734-572-9760
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39650 ORCHARD HILL PL STE 200
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48375-5391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-319-0161
-----------------------------------------------------
Fax | 248-319-0170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 35-06-3107
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | 4301406847
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------