Healthcare Provider Details

I. General information

NPI: 1184112344
Provider Name (Legal Business Name): MAX CHRISTIAN PETERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV IM ENDOCRINOLOGY, STE 13B
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-3500
  • Fax: 314-230-1119
Mailing address:
  • Phone: 314-362-3500
  • Fax: 314-230-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2020015426
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2020015426
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2020015426
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number2020015426
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: