Healthcare Provider Details

I. General information

NPI: 1417958026
Provider Name (Legal Business Name): ELIZABETH MICHAEL PETERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WARREN ST SUITE 4
BEAVER DAM WI
53916-3082
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 920-885-3305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46524-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: