Provider Demographics
NPI:1457475550
Name:PETOSKEY FAMILY MEDICINE, P.C.
Entity Type:Organization
Organization Name:PETOSKEY FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:231-487-6000
Mailing Address - Street 1:1890 US 131 SOUTH
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-487-6000
Mailing Address - Fax:231-487-6014
Practice Address - Street 1:1890 US 131 SOUTH
Practice Address - Street 2:SUITE 3
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-487-6000
Practice Address - Fax:231-487-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID