Provider Demographics
NPI:1225243157
Name:PETROSKY, MICHAEL JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
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:PO BOX 836
Mailing Address - Street 2:
Mailing Address - City:ABITA SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70420-0836
Mailing Address - Country:US
Mailing Address - Phone:985-893-1181
Mailing Address - Fax:985-893-0414
Practice Address - Street 1:71623 HICKORY ST.
Practice Address - Street 2:
Practice Address - City:ABITA SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70420
Practice Address - Country:US
Practice Address - Phone:985-893-1181
Practice Address - Fax:985-893-0414
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1013111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5D366Medicare ID - Type Unspecified
LA435580Medicare UPIN