MEDICARE: DR. GREGORY JOSEPH PETERSEN D.C.

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	111N00000X	Chiropractor	5767	MN

General Provider Information

NPI Number	:	1851631907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY JOSEPH PETERSEN D.C.

Provider Business Mailing Address
First Line	:	9505 BLACKOAKS LN N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-1229
Country	:	US
Telephone Number	:	763-420-4111
Fax Number	:	763-420-4145

Provider Business Practice Location Address
First Line	:	9505 BLACKOAKS LN N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-1229
Country	:	US
Telephone Number	:	763-420-4111
Fax Number	:	763-420-4145

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

Provider Enumeration Date	:	02/27/2013
Last Update Date	:	02/27/2013

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