Provider Demographics
NPI:1124139688
Name:PETROSKI, MICHAEL EDWARD (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:PETROSKI
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 1:1520 SANSOM ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2804
Mailing Address - Country:US
Mailing Address - Phone:215-564-4700
Mailing Address - Fax:215-564-4700
Practice Address - Street 1:1520 SANSOM ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2804
Practice Address - Country:US
Practice Address - Phone:215-564-4700
Practice Address - Fax:215-564-4700
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 003761-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0114798000OtherBLUE CROSS #
PAPE1763163OtherBLUE CHOICE #
PAPE533470Medicare ID - Type UnspecifiedMEDICARE ID
PAPE1763163OtherBLUE CHOICE #