Provider Demographics
NPI:1184632622
Name:PETROSKY, MICHAEL R (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:PETROSKY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 NEWTOWN YARDLEY RD
Mailing Address - Street 2:STE 2E
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940
Mailing Address - Country:US
Mailing Address - Phone:215-968-1711
Mailing Address - Fax:215-860-1976
Practice Address - Street 1:638 NEWTOWN YARDLEY RD
Practice Address - Street 2:STE 2E
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940
Practice Address - Country:US
Practice Address - Phone:215-968-1711
Practice Address - Fax:215-860-1976
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009308111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0005067049OtherAETNA
2451693000OtherKEYSTONE
V02224Medicare UPIN
2451693000OtherKEYSTONE