Healthcare Provider Details

I. General information

NPI: 1619091873
Provider Name (Legal Business Name): LINDA M PETERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W GREENLAWN AVE W 218
LANSING MI
48910-2819
US

IV. Provider business mailing address

3061 CHRISTY WAY
SAGINAW MI
48603-2267
US

V. Phone/Fax

Practice location:
  • Phone: 517-334-2757
  • Fax:
Mailing address:
  • Phone: 989-791-2455
  • Fax: 989-791-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301064361
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: