Provider Demographics
NPI:1528081213
Name:PETTERUTI, KATHY M (DO)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:M
Last Name:PETTERUTI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 E 10 MILE RD
Mailing Address - Street 2:SUITE 229
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2048
Mailing Address - Country:US
Mailing Address - Phone:586-758-6263
Mailing Address - Fax:586-758-7725
Practice Address - Street 1:13355 E 10 MILE RD
Practice Address - Street 2:SUITE 229
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2048
Practice Address - Country:US
Practice Address - Phone:586-758-6263
Practice Address - Fax:586-758-7725
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007608207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1425614Medicaid
B47593Medicare UPIN