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General NPI Number Information
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NPI Number | 1861693095
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Entity Type | Individual
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Provider Name | BRIAN WALTER PETERSEN D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/28/2007
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Last Update Date | 09/30/2025
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Provider Practice Location Address
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Address Line | 482 INTERSTATE DR STE 102
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City | MANCHESTER
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State | TN
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Zip | 37355-3485
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Country | US
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Telephone | 931-488-8700
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Fax | 931-735-6456
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Provider Business Mailing Address
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Address Line | 111 MOSBY CT
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City | SHELBYVILLE
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State | TN
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Zip | 37160-7179
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Country | US
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Telephone |
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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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 2291
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | TL1160
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License Number State | WY
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