Healthcare Provider Details

I. General information

NPI: 1649250242
Provider Name (Legal Business Name): SCOTT M PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 11/27/2023
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W CENTRE AVE BRONSON OB GYN ASSOCIATES
PORTAGE MI
49024-4666
US

IV. Provider business mailing address

601 JOHN ST BOX 42
KALAMAZOO MI
49007-5341
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-2211
  • Fax: 269-327-0273
Mailing address:
  • Phone: 269-341-7806
  • Fax: 269-341-8743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301068138
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: