Healthcare Provider Details

I. General information

NPI: 1588581854
Provider Name (Legal Business Name): WILLIAM THOMAS PETERSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 SHAWNEE DR
FINKSBURG MD
21048-1408
US

IV. Provider business mailing address

2408 SHAWNEE DR
FINKSBURG MD
21048-1408
US

V. Phone/Fax

Practice location:
  • Phone: 508-210-6016
  • Fax:
Mailing address:
  • Phone: 508-210-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA6197
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: