MEDICARE: KEITH MICHAEL PETRAS M.D.

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
1	207RN0300X	Nephrology Physician	35-080986P	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215997770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH MICHAEL PETRAS M.D.

Provider Business Mailing Address
First Line	:	20455 LORAIN RD
Second Line	:	SUITE T01
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-3494
Country	:	US
Telephone Number	:	440-799-4224
Fax Number	:	440-799-4228

Provider Business Practice Location Address
First Line	:	7225 OLD OAK BLVD
Second Line	:	STE B313
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-3339
Country	:	US
Telephone Number	:	440-243-0574
Fax Number	:	440-243-0582

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	02/16/2015

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