Provider Demographics
NPI:1467433516
Name:PETROFF, CHRISTY A (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:A
Last Name:PETROFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:7815 E JEFFERSON AVE
Practice Address - Street 2:1B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3704
Practice Address - Country:US
Practice Address - Phone:313-499-4312
Practice Address - Fax:313-499-4863
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4647803Medicaid
5315019604OtherCONTROLLED SUBSTANCE