Provider Demographics
NPI:1629005160
Name:PETERSEN, MICHAEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39650 ORCHARD HILL PL STE 200
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5391
Mailing Address - Country:US
Mailing Address - Phone:248-319-0161
Mailing Address - Fax:248-319-0170
Practice Address - Street 1:2000 N HURON RIVER DR STE 100
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-572-1200
Practice Address - Fax:734-572-9760
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-3107207W00000X
MI4301406847207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH180026057OtherRAIL ROAD MEDICARE
IN100374400Medicaid
000000021228OtherBCBS
OH0886528Medicaid
KY64930167Medicaid