Provider Demographics
NPI:1891740205
Name:PETTERUTO, MICHAEL STEPHEN (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:PETTERUTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 CHAPLIN DR
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816
Mailing Address - Country:US
Mailing Address - Phone:401-392-3351
Mailing Address - Fax:401-392-3051
Practice Address - Street 1:234 CHAPLIN DR
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816
Practice Address - Country:US
Practice Address - Phone:401-392-3351
Practice Address - Fax:401-392-3051
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00383111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI6152953OtherCIGNA
RI21331430OtherAETNA
RI404806OtherBLUE CHIP
RI2822-8OtherBLUE CROSS
U72007Medicare UPIN