Basic Information
| Provider Information | |||||||||
| NPI: | 1750404612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETROVICH | ||||||||
| FirstName: | MARLENE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1640 FORT ST | ||||||||
| Address2: | SUITE D ATTN DENISE | ||||||||
| City: | TRENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481832040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343913057 | ||||||||
| FaxNumber: | 7343913052 | ||||||||
| Practice Location | |||||||||
| Address1: | 23050 WEST RD | ||||||||
| Address2: | SUITE210 | ||||||||
| City: | BROWNSTOWN TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481831472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343627000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2007 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 4704100811 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 1144634403 | 01 | GROUP NPI HENRY FORD WYANDOTTE | OTHER | 0H28865 | 01 | MI | BLUE CROSS | OTHER |