MEDICARE: DR. MICHAEL PETERSEN DVM

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	174M00000X	Veterinarian	04212	MN

General Provider Information

NPI Number	:	1740602960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL PETERSEN DVM

Provider Business Mailing Address
First Line	:	5754 NICOLLET AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-2415
Country	:	US
Telephone Number	:	612-866-7103
Fax Number	:	612-866-0250

Provider Business Practice Location Address
First Line	:	5754 NICOLLET AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-2415
Country	:	US
Telephone Number	:	612-866-7103
Fax Number	:	612-866-0250

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

Provider Enumeration Date	:	01/07/2014
Last Update Date	:	01/07/2014

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