MEDICARE: MICHAEL LLOYD PETRANEK DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	507	NC
2	213ES0103X	Foot & Ankle Surgery Podiatrist	0103300947	VA

General Provider Information

NPI Number	:	1265449508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LLOYD PETRANEK DPM

Provider Business Mailing Address
First Line	:	9918 MAIN ST
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-3901
Country	:	US
Telephone Number	:	703-273-9818
Fax Number	:	866-453-6775

Provider Business Practice Location Address
First Line	:	9918 MAIN ST
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-3901
Country	:	US
Telephone Number	:	703-273-9818
Fax Number	:	866-453-6775

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	01/05/2015

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