MEDICARE: DR. BROOKE A. PETERSON

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	183500000X	Pharmacist	5302034004	MI

General Provider Information

NPI Number	:	1740502061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROOKE A. PETERSON

Provider Business Mailing Address
First Line	:	1010 MONTERREY TRL
Second Line	:
City	:	LAKE ISABELLA
State	:	MI
Zip	:	48893-8204
Country	:	US
Telephone Number	:	989-644-8088
Fax Number	:

Provider Business Practice Location Address
First Line	:	2125 S MISSION ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-4426
Country	:	US
Telephone Number	:	989-773-6991
Fax Number	:

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

Provider Enumeration Date	:	03/01/2010
Last Update Date	:	03/01/2010

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