Basic Information
| Provider Information | |||||||||
| NPI: | 1629005160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39650 ORCHARD HILL PL STE 200 | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483190161 | ||||||||
| FaxNumber: | 2483190170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 N HURON RIVER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345721200 | ||||||||
| FaxNumber: | 7345729760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 35-06-3107 | OH | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 4301406847 | MI | Y |
ID Information
| ID | Type | State | Issuer | Description | 180026057 | 01 | OH | RAIL ROAD MEDICARE | OTHER | 100374400 | 05 | IN | MEDICAID | 000000021228 | 01 | BCBS | OTHER | 0886528 | 05 | OH | MEDICAID | 64930167 | 05 | KY | MEDICAID |