Provider Demographics
NPI:1154740942
Name:PETROS, WASEEM GHANIM (MD)
Entity type:Individual
Prefix:
First Name:WASEEM
Middle Name:GHANIM
Last Name:PETROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 LIVERNOIS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1603
Mailing Address - Country:US
Mailing Address - Phone:248-250-8233
Mailing Address - Fax:248-250-9483
Practice Address - Street 1:2221 LIVERNOIS RD STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1603
Practice Address - Country:US
Practice Address - Phone:248-250-9474
Practice Address - Fax:248-250-9483
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105506207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty