Healthcare Provider Details

I. General information

NPI: 1255727863
Provider Name (Legal Business Name): ERIC PETERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 07/24/2023
Certification Date: 06/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E MCDOWELL RD
PHOENIX AZ
85006-2612
US

IV. Provider business mailing address

TRAUMA AND EMERGENCY SURGERY SERVICE 1111 E MCDOWELL RD
PHOENIX AZ
85006-2612
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-5968
  • Fax: 602-521-5988
Mailing address:
  • Phone: 602-839-3644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number70554
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number70554
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number70554
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: