MEDICARE: DR. HORACE REX PETERSEN D.O.

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	207X00000X	Orthopaedic Surgery Physician	R9N57	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13190	OTHER	MO	BLUE CROSS

General Provider Information

NPI Number	:	1568460590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HORACE REX PETERSEN D.O.

Provider Business Mailing Address
First Line	:	4040 LA QUESTA DR
Second Line	:
City	:	NEOSHO
State	:	MO
Zip	:	64850-2849
Country	:	US
Telephone Number	:	417-451-1833
Fax Number	:	417-451-1825

Provider Business Practice Location Address
First Line	:	4040 LA QUESTA DR
Second Line	:
City	:	NEOSHO
State	:	MO
Zip	:	64850-2849
Country	:	US
Telephone Number	:	417-451-1833
Fax Number	:	417-451-1825

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	07/08/2007

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