Provider Demographics
NPI:1417943614
Name:KRENITSKY, PETER (D O)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KRENITSKY
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13251 E 10 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2076
Mailing Address - Country:US
Mailing Address - Phone:586-758-7880
Mailing Address - Fax:586-758-2635
Practice Address - Street 1:13251 E 10 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2076
Practice Address - Country:US
Practice Address - Phone:586-758-7880
Practice Address - Fax:586-758-2635
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5500963OtherBLUE CROSS BLUE SHIELD
MI1026674Medicaid
MI1026674Medicaid
MIOM98900001Medicare ID - Type Unspecified