Provider Demographics
NPI:1205295193
Name:PETROS, SALEM
Entity type:Individual
Prefix:
First Name:SALEM
Middle Name:
Last Name:PETROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12206 CASTLE PINES DR
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1146
Mailing Address - Country:US
Mailing Address - Phone:240-432-7938
Mailing Address - Fax:
Practice Address - Street 1:12206 CASTLE PINES DR
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1146
Practice Address - Country:US
Practice Address - Phone:240-432-7938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR130643286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital