Provider Demographics
NPI:1609221969
Name:PETRIDES, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETRIDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:1 SILVERSTEIN, SUITE 130
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-6918
Mailing Address - Fax:215-662-2664
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:1 SILVERSTEIN, SUITE 130
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-6918
Practice Address - Fax:215-662-2664
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2238062085N0904X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program