Provider Demographics
NPI:1689930679
Name:PERETIN, STEPHEN D (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:PERETIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 BIDDLE AVE
Mailing Address - Street 2:HENRY FORD WYANDOTTE HOSPITAL
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:HENRY FORD WYANDOTTE HOSPITAL
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192
Practice Address - Country:US
Practice Address - Phone:734-246-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
IN02004904A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN364430297OtherMEDICARE PTAN
IN201382880Medicaid