1124005822 NPI number — DANIEL PETERSON MD

Table of content: DANIEL PETERSON MD (NPI 1124005822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124005822 NPI number — DANIEL PETERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
DANIEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1124005822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 9TH ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55904-6756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-288-3443
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 9TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55904-6756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-288-3443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/23/2005

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: 207W00000X , with the licence number:  44050 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 44T5PE , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 969670900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 577577 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MH9041041407 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 141091 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08-01109 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2159678 . This is a "ARAZ" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9898 . This is a "AVERA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP42865 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 444T5PE . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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