Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2301400102 | MI |
NPI | 1619952496 |
---|---|
Provider Name | Dr. Philip F. Petsch |
First Address | Whitehall, MI 49461-2005 |
Second Address | Whitehall, MI 49461-2005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2005 |
Last Update Date | 08/07/2007 |