Provider Demographics
NPI:1275585887
Name:METROPOULOS, PETER E (DO MPH FACOEM)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:METROPOULOS
Suffix:
Gender:M
Credentials:DO MPH FACOEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11477 EAST 12 MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2678
Mailing Address - Country:US
Mailing Address - Phone:586-751-0200
Mailing Address - Fax:586-751-0414
Practice Address - Street 1:11477 EAST 12 MILE ROAD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2678
Practice Address - Country:US
Practice Address - Phone:586-751-0200
Practice Address - Fax:586-751-0414
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010989207R00000X, 202C00000X, 2083X0100X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4149936Medicaid
MI5101010989OtherMICHIGAN - MEDICAL LICESNE NUMBER
MIOM85900009Medicare ID - Type Unspecified
MI4149936Medicaid