Provider Demographics
NPI:1578542452
Name:PETROFF, THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PETROFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:2445 JOLLY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4590
Practice Address - Country:US
Practice Address - Phone:517-347-4040
Practice Address - Fax:517-347-4109
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011412207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG13956OtherHEALTH NET FEDERAL SERVIC
MI0700090OtherPHYSICIANS HEALTH PLAN
MI4308415Medicaid
MI1653300644OtherBLUE CROSS BLUE SHIELD
MI252501OtherHEALTH ADVANTAGE NETWORK
MI252501OtherMCLAREN HEALTH PLAN
MI4651172OtherAETNA
MI1653300644OtherBLUE CROSS BLUE SHIELD