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General NPI Number Information
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NPI Number | 1609079094
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Entity Type | Individual
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Provider Name | MICHAEL GENE PETERSON MD
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Gender | Male
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 02/11/2010
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Provider Practice Location Address
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Address Line | 201 E. NICOLLET BLVD.
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City | BURNSVILLE
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State | MN
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Zip | 55337
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Country | US
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Telephone | 612-889-5480
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Fax |
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Provider Business Mailing Address
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Address Line | 5435 FELTL RD
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City | MINNETONKA
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State | MN
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Zip | 55343-7983
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Country | US
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Telephone | 952-857-1504
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 4301085530
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 52328
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License Number State | MN
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