Healthcare Provider Details

I. General information

NPI: 1295730661
Provider Name (Legal Business Name): PHILLIP H PETERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CEDAR ST
OROFINO ID
83544-9029
US

IV. Provider business mailing address

301 CEDAR ST
OROFINO ID
83544-9029
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-4555
  • Fax: 208-476-5385
Mailing address:
  • Phone: 208-476-4555
  • Fax: 208-476-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM5405
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: