Provider Demographics
NPI:1114121282
Name:STEVEN L PETERSON PROFESSIONAL LLC
Entity Type:Organization
Organization Name:STEVEN L PETERSON PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-254-1686
Mailing Address - Street 1:2754 COMPASS DR
Mailing Address - Street 2:STE 300
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8714
Mailing Address - Country:US
Mailing Address - Phone:970-254-1686
Mailing Address - Fax:970-254-1687
Practice Address - Street 1:1120 WELLINGTON AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6129
Practice Address - Country:US
Practice Address - Phone:970-254-1686
Practice Address - Fax:970-254-1687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO355502086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG0363OtherRAILROAD MEDICARE
COC808753Medicare PIN