Provider Demographics
NPI:1902853252
Name:PETTY-DUDLEY, MARY E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:PETTY-DUDLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:30274 YOUNG DR
Mailing Address - Street 2:
Mailing Address - City:GIBRALTAR
Mailing Address - State:MI
Mailing Address - Zip Code:48173-9457
Mailing Address - Country:US
Mailing Address - Phone:313-831-8303
Mailing Address - Fax:313-831-8307
Practice Address - Street 1:3 HERITAGE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-3000
Practice Address - Country:US
Practice Address - Phone:734-283-3222
Practice Address - Fax:734-283-4006
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMP058113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110825451OtherBCBS
MI102435OtherGREAT LAKES
MIMP058113OtherBCBS
MI4503142 TYPE 10Medicaid
MIP32340001Medicare PIN
MI0P32340Medicare PIN
MI4503142 TYPE 10Medicaid