Provider Demographics
NPI:1497911150
Name:MICHAEL PETROSKY
Entity Type:Organization
Organization Name:MICHAEL PETROSKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-421-1242
Mailing Address - Street 1:120 VANN ST NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7357
Mailing Address - Country:US
Mailing Address - Phone:770-421-1242
Mailing Address - Fax:
Practice Address - Street 1:120 VANN ST NE
Practice Address - Street 2:SUITE 150
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7357
Practice Address - Country:US
Practice Address - Phone:770-421-1242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE19976Medicare UPIN