Provider Demographics
NPI:1235169384
Name:PETERSEN CLINIC, PLLC
Entity Type:Organization
Organization Name:PETERSEN CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:N
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-465-0544
Mailing Address - Street 1:119 MAIN ST W
Mailing Address - Street 2:SUITE A
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-2943
Mailing Address - Country:US
Mailing Address - Phone:304-465-0544
Mailing Address - Fax:304-465-8832
Practice Address - Street 1:119 MAIN ST W
Practice Address - Street 2:SUITE A
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-2943
Practice Address - Country:US
Practice Address - Phone:304-465-0544
Practice Address - Fax:304-465-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV942207Q00000X
WV1864207Q00000X
WV941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0084786001Medicaid
PE9318551Medicare ID - Type Unspecified