Provider Demographics
NPI:1518014331
Name:GHERAIBEH, PETRA (MD)
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:GHERAIBEH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 W OUTER DR
Mailing Address - Street 2:SUITE # 1 MAIN
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-966-1008
Mailing Address - Fax:313-966-9510
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:SUITE # 1 MAIN
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-966-1008
Practice Address - Fax:313-966-9510
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091043207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC340526Medicaid