Healthcare Provider Details

I. General information

NPI: 1033539937
Provider Name (Legal Business Name): ADAM PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 N LEWIS AVE
SIOUX FALLS SD
57104-7111
US

IV. Provider business mailing address

1900 E BRIAR DEN CT
SIOUX FALLS SD
57108-5112
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-6368
  • Fax:
Mailing address:
  • Phone: 605-940-1450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number11710
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: