Healthcare Provider Details

I. General information

NPI: 1841255460
Provider Name (Legal Business Name): JODI PETERSON MCGRAW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI L PETERSON MD

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 QUAIL RIDGE DR
BARNEVELD WI
53507-9408
US

IV. Provider business mailing address

103 QUAIL RIDGE DR
BARNEVELD WI
53507-9408
US

V. Phone/Fax

Practice location:
  • Phone: 608-924-3939
  • Fax: 608-924-3999
Mailing address:
  • Phone: 608-924-3939
  • Fax: 608-924-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39202-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: