MEDICARE: LORI PETERSON M.D.

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
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	26412	CO

General Provider Information

NPI Number	:	1558307884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI PETERSON M.D.

Provider Business Mailing Address
First Line	:	1892 WILLIAMS STREET
Second Line	:
City	:	FT. HARRISON
State	:	MT
Zip	:	59636
Country	:	US
Telephone Number	:	406-447-7553
Fax Number	:	406-447-7991

Provider Business Practice Location Address
First Line	:	1892 WILLIAMS STREET
Second Line	:
City	:	FT. HARRISON
State	:	MT
Zip	:	59636
Country	:	US
Telephone Number	:	406-447-7553
Fax Number	:	406-447-7991

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	07/08/2007

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