Healthcare Provider Details

I. General information

NPI: 1780768937
Provider Name (Legal Business Name): BRUCE A PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE STREET SE
MINNEAPOLIS MN
55455
US

IV. Provider business mailing address

UNIVERSITY OF MINNESOTA PHYSICIANS 420 DELAWARE STREET SE
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-5411
  • Fax:
Mailing address:
  • Phone: 612-625-5411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number20660
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: