Healthcare Provider Details

I. General information

NPI: 1780678318
Provider Name (Legal Business Name): PATTI LYNN PETERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 PYLE DR
KINGSFORD MI
49802-1132
US

IV. Provider business mailing address

1205 PYLE DR
KINGSFORD MI
49802-1132
US

V. Phone/Fax

Practice location:
  • Phone: 906-779-7100
  • Fax: 906-779-7101
Mailing address:
  • Phone: 906-779-7100
  • Fax: 906-779-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301045762
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: