Healthcare Provider Details

I. General information

NPI: 1851666168
Provider Name (Legal Business Name): REBECCA J PETERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 GREELEY ST S
STILLWATER MN
55082-5935
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-1234
  • Fax:
Mailing address:
  • Phone: 952-883-7165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number60554
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: