Healthcare Provider Details

I. General information

NPI: 1508170457
Provider Name (Legal Business Name): KATHERINE A PETERSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 REYNOLDS ST STE 202
SAVANNAH GA
31405-6009
US

IV. Provider business mailing address

PO BOX 919
RINCON GA
31326-0919
US

V. Phone/Fax

Practice location:
  • Phone: 912-352-0920
  • Fax:
Mailing address:
  • Phone: 912-352-0920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number82882
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number48313
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: