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NPI Code Detail

MEDICARE: BRYAN TUTT PETERSEN MD

MEDICARE: BRYAN TUTT PETERSEN MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician39514MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1356339436
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRYAN TUTT PETERSEN MD
Provider Business Mailing Address
First Line : 1805 HENNEPIN AVE N
Second Line : GLENCOE REGIONAL HEALTH SERVICES
City : GLENCOE
State : MN
Zip : 55336-1416
Country : US
Telephone Number : 320-864-3121
Fax Number : 320-864-7887
Provider Business Practice Location Address
First Line : 1805 HENNEPIN AVE N
Second Line : GLENCOE REGIONAL HEALTH SERVICES
City : GLENCOE
State : MN
Zip : 55336-1416
Country : US
Telephone Number : 320-864-3121
Fax Number : 320-864-7887
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/12/2005
Last Update Date : 11/24/2020

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Directions to “ BRYAN TUTT PETERSEN MD” Practice Location

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