Provider Demographics
NPI:1609849736
Name:PETERSEN, MICHAEL T (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MAIN PL
Mailing Address - Street 2:SUITE 425
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-0792
Mailing Address - Country:US
Mailing Address - Phone:712-322-5565
Mailing Address - Fax:712-322-5566
Practice Address - Street 1:25 MAIN PL
Practice Address - Street 2:SUITE 425
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-0792
Practice Address - Country:US
Practice Address - Phone:712-322-5565
Practice Address - Fax:712-322-5566
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28268207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA075051Medicaid
B67659Medicare UPIN
043547Medicare ID - Type Unspecified