Healthcare Provider Details

I. General information

NPI: 1912296757
Provider Name (Legal Business Name): ROBERT LYNN PETERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5380
  • Fax: 314-268-4141
Mailing address:
  • Phone: 314-577-5380
  • Fax: 314-268-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014011778
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number2014011778
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: