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NPI Code Detail

MEDICARE: KETTI SOPHIA PETERSEN MD

MEDICARE: KETTI SOPHIA PETERSEN MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QH0002XHospice and Palliative Medicine (Family Medicine) Physician4301096617MI
2207Q00000XFamily Medicine Physician4301096617MI

General Provider Information

NPI Number : 1003128919
Entity Type Code : Individual
Provider Name (Legal Business Name) : KETTI SOPHIA PETERSEN MD
Provider Business Mailing Address
First Line : 3621 S STATE ST
Second Line :
City : ANN ARBOR
State : MI
Zip : 48108-1633
Country : US
Telephone Number : 734-647-5299
Fax Number :
Provider Business Practice Location Address
First Line : 1500 E MEDICAL CENTER DR
Second Line :
City : ANN ARBOR
State : MI
Zip : 48109-5000
Country : US
Telephone Number : 734-936-4000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/08/2010
Last Update Date : 11/11/2020

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