Healthcare Provider Details

I. General information

NPI: 1639710882
Provider Name (Legal Business Name): PETERSEN NEUROSPINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPORT BLVD BUILDING D SUITE 100
MOBILE AL
36608-6765
US

IV. Provider business mailing address

6701 AIRPORT BLVD BUILDING D SUITE 100
MOBILE AL
36608-6765
US

V. Phone/Fax

Practice location:
  • Phone: 251-607-6117
  • Fax: 251-219-0746
Mailing address:
  • Phone: 251-607-6117
  • Fax: 251-219-0746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: BENDT P PETERSEN III
Title or Position: PHYSICIAN
Credential: MD
Phone: 251-607-6117