MEDICARE: DR. RENEE IRENE PETHTEL D.C.

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	111N00000X	Chiropractor	2301007287	MI

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
2	950H253460	OTHER	MI	BCBS PPO
3	140343	OTHER	MI	PREFERRED CHOICES
4	P101064	OTHER	MI	BLUECARE NETWORK
5	11285842	OTHER	MI	CAQH
6	RP007287	OTHER	MI	BCBS ID
7	U61953	OTHER	MI	HAP

General Provider Information

NPI Number	:	1760431977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENEE IRENE PETHTEL D.C.

Provider Business Mailing Address
First Line	:	23610 VAN BORN RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2356
Country	:	US
Telephone Number	:	313-291-1060
Fax Number	:	313-291-1089

Provider Business Practice Location Address
First Line	:	23610 VAN BORN RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2356
Country	:	US
Telephone Number	:	313-291-1060
Fax Number	:	313-291-1089

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	02/05/2024

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