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General NPI Number Information
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NPI Number | 1245957737
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Entity Type | Organization
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Legal Business Name | PETERSEN CONCIERGE MEDICAL
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Dates
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Enumeration Date | 10/25/2022
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Last Update Date | 10/25/2022
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Provider Practice Location Address
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Address Line | 2315 MCDONALD AVE
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City | MISSOULA
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State | MT
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Zip | 59801-7342
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Country | US
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Telephone | 406-541-7040
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Fax | 406-830-3123
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Provider Business Mailing Address
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Address Line | 2315 MCDONALD AVE
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City | MISSOULA
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State | MT
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Zip | 59801-7342
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Country | US
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Telephone | 406-499-1354
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Fax | 406-830-3123
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Authorized Official
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Title or Position | CEO
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Name | DR. CAMILLA ESTHER JUHL PETERSEN
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Credential | MD
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Telephone | 406-541-7040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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