MEDICARE: DR. JON ERIC PETTERSON 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	207Q00000X	Family Medicine Physician	MD11174	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MD11174	OTHER	OR	STATE MED LIC

General Provider Information

NPI Number	:	1699709253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON ERIC PETTERSON M.D.

Provider Business Mailing Address
First Line	:	3175 POCAHONTAS RD
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-1434
Country	:	US
Telephone Number	:	541-523-4415
Fax Number	:	541-523-2399

Provider Business Practice Location Address
First Line	:	3175 POCAHONTAS RD
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-1434
Country	:	US
Telephone Number	:	541-523-4415
Fax Number	:	541-523-2399

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/09/2007

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