Provider Demographics
NPI:1174668081
Name:PETERSON, TIMOTH Y JOHN
Entity Type:Individual
Prefix:
First Name:TIMOTH Y
Middle Name:JOHN
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 1:213 E CECIL AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-1416
Mailing Address - Country:US
Mailing Address - Phone:218-736-3507
Mailing Address - Fax:
Practice Address - Street 1:ST. FRANCIS HEALTHCARE CAMPUS
Practice Address - Street 2:2400 ST. FRANCIS DRIVE
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520
Practice Address - Country:US
Practice Address - Phone:218-643-0345
Practice Address - Fax:218-643-0853
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102006282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access