Healthcare Provider Details

I. General information

NPI: 1134211568
Provider Name (Legal Business Name): TIMOTHY A PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 S WASHINGTON ST STE G
GRAND FORKS ND
58201-8123
US

IV. Provider business mailing address

PO BOX 5210
GRAND FORKS ND
58206-5210
US

V. Phone/Fax

Practice location:
  • Phone: 701-205-3000
  • Fax: 701-732-2501
Mailing address:
  • Phone: 701-205-3000
  • Fax: 701-732-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number7777
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number7777
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7777
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: