1710928486 NPI number — PHILLIP K PETERSON MD

Table of content: PHILLIP K PETERSON MD (NPI 1710928486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710928486 NPI number — PHILLIP K PETERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
PHILLIP
Provider Middle Name:
K
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:
1710928486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 WASHINGTON AVE SE
Provider Second Line Business Mailing Address:
UNIVERSITY OF MINNESOTA PHYSICIANS
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-884-0649
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 DELAWARE STREET SE
Provider Second Line Business Practice Location Address:
UMP DELAWARE STREET CLINIC
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-884-0649
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2006

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: 207RI0200X , with the licence number:  22228 , 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: 112270300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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