Basic Information
| Provider Information | |||||||||
| NPI: | 1003270422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRY | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025599407 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 6411 VETERANS MEMORIAL PKWY | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400148698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022418611 | ||||||||
| FaxNumber: | 5022414175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2016 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | R4220 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.