Provider Demographics
NPI:1124221668
Name:MACERONI, PETER JOSEPH JR (DO)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:MACERONI
Suffix:JR
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 1:46591 ROMEO PLANK RD STE 220
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5705
Mailing Address - Country:US
Mailing Address - Phone:586-226-6170
Mailing Address - Fax:586-226-6168
Practice Address - Street 1:46591 ROMEO PLANK RD STE 220
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5705
Practice Address - Country:US
Practice Address - Phone:586-226-6170
Practice Address - Fax:586-226-6168
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010172042084N0400X
OH34.0119782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9934723OtherMEDICARE GROUP PTAN
OH1184652539OtherGROUP NPI
OHH440720OtherMEDICARE PTAN
MI1124221668Medicaid