Provider Demographics
NPI:1164698130
Name:ROBERT G. PETERSON, D.C., P.C.
Entity Type:Organization
Organization Name:ROBERT G. PETERSON, D.C., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-449-4757
Mailing Address - Street 1:24360 NOVI RD
Mailing Address - Street 2:B-1
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2404
Mailing Address - Country:US
Mailing Address - Phone:248-449-4757
Mailing Address - Fax:248-735-2446
Practice Address - Street 1:24360 NOVI RD
Practice Address - Street 2:B-1
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2404
Practice Address - Country:US
Practice Address - Phone:248-449-4757
Practice Address - Fax:248-735-2446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F328130OtherBLUE CROSS BLUE SHIELD
MI0M87600Medicare PIN
MIU76994Medicare UPIN