Healthcare Provider Details

I. General information

NPI: 1104280700
Provider Name (Legal Business Name): KYLE PETERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2016
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 BURNS RD STE 100
PALM BEACH GARDENS FL
33410-4627
US

IV. Provider business mailing address

4215 BURNS RD STE 200
PALM BEACH GARDENS FL
33410-4625
US

V. Phone/Fax

Practice location:
  • Phone: 561-694-7776
  • Fax: 561-694-3099
Mailing address:
  • Phone: 561-694-7776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME155351
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: