Provider Demographics
NPI:1669664173
Name:PETRICH, MICHAEL PAULY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PAULY
Last Name:PETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:18060 SNOW ROAD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-436-2583
Mailing Address - Fax:313-436-2809
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-436-2583
Practice Address - Fax:313-436-2809
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010842892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology