1184112344 NPI number — DR. MAX CHRISTIAN PETERSEN MD, PHD

Table of content: DR. MAX CHRISTIAN PETERSEN MD, PHD (NPI 1184112344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184112344 NPI number — DR. MAX CHRISTIAN PETERSEN MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
MAX
Provider Middle Name:
CHRISTIAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184112344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 PASADENA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBSTER GROVES
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63119-3127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-207-7393
Provider Business Mailing Address Fax Number:
314-747-3963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4921 PARKVIEW PL STE 5C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63110-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-362-3500
Provider Business Practice Location Address Fax Number:
314-747-3963
Provider Enumeration Date:
04/24/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  2020015426 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)