Provider Demographics
NPI:1275640062
Name:PETERSON, CATHERINE JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:JANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BLAZEDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6311
Mailing Address - Country:US
Mailing Address - Phone:636-227-9801
Mailing Address - Fax:
Practice Address - Street 1:233 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2219
Practice Address - Country:US
Practice Address - Phone:636-256-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110701146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH11047Medicare ID - Type Unspecified