Healthcare Provider Details

I. General information

NPI: 1881798379
Provider Name (Legal Business Name): MICHAEL CHARLES PETERSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12356 RIATA TRACE PKWY # 6006-B
AUSTIN TX
78727-6417
US

IV. Provider business mailing address

12356 RIATA TRACE PKWY # 6006-B
AUSTIN TX
78727-6417
US

V. Phone/Fax

Practice location:
  • Phone: 512-506-7000
  • Fax: 314-251-4450
Mailing address:
  • Phone: 512-506-7000
  • Fax: 314-251-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006027561
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberQ2049
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: