Provider Demographics
NPI:1629078878
Name:PETRI, MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PETRI
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SE OSCEOLA ST # 3
Mailing Address - Street 2:PO BOX 868
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2505
Mailing Address - Country:US
Mailing Address - Phone:772-286-0338
Mailing Address - Fax:772-287-1139
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:772-286-0338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285765367500000X
FLARNP 9263613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG4381OtherFLORIDA BCBS
FL308745000Medicaid
NY0422BGMedicare ID - Type UnspecifiedGHI MEDICARE
NYR3A611Medicare ID - Type UnspecifiedEMPIRE MEDICARE
FLAH376ZMedicare PIN