MEDICARE: PETERSON MEDICAL CLINICS, LLC

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	2084P0800X	Psychiatry Physician
2	261QM1300X	Multi-Specialty Clinic/Center		ND

General Provider Information

NPI Number	:	1699295774
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON MEDICAL CLINICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 5210
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58206-5210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3674 S WASHINGTON ST
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-5766
Country	:	US
Telephone Number	:	701-205-3000
Fax Number	:	701-732-2501

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS M PETERSON
Credential	:	MD
Telephone Number	:	701-205-3000

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	10/01/2025

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