Provider Demographics
NPI:1154847069
Name:PETERSON, GREG ROBERT
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 E 29TH CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2112
Mailing Address - Country:US
Mailing Address - Phone:563-370-7061
Mailing Address - Fax:563-421-6099
Practice Address - Street 1:2723 E 29TH CT
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2112
Practice Address - Country:US
Practice Address - Phone:563-370-7061
Practice Address - Fax:563-421-6099
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA580AH7464343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)