Healthcare Provider Details

I. General information

NPI: 1285621516
Provider Name (Legal Business Name): JON FREDRICK PETERSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E LAKE SHORE DR
DECATUR IL
62521-3803
US

IV. Provider business mailing address

1750 E LAKE SHORE DR
DECATUR IL
62521-3803
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-1440
  • Fax: 217-464-1469
Mailing address:
  • Phone: 217-464-1440
  • Fax: 217-464-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036129728
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036129728
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: