Healthcare Provider Details

I. General information

NPI: 1265454490
Provider Name (Legal Business Name): STEVEN MICHAEL PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 AUDUBON PLAZA DR STE 560 AUDUBON MEDICAL PLAZA EAST
LOUISVILLE KY
40217-1376
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-636-8004
  • Fax: 502-636-8384
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number46689
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: