Provider Demographics
NPI:1275718280
Name:MICHAEL J. PETERSON M.D LLC
Entity Type:Organization
Organization Name:MICHAEL J. PETERSON M.D LLC
Other - Org Name:HERRIMAN FAMILY MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-253-4001
Mailing Address - Street 1:5746 W 13400 S
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6907
Mailing Address - Country:US
Mailing Address - Phone:801-253-4001
Mailing Address - Fax:801-253-4003
Practice Address - Street 1:5746 W 13400 S
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-6907
Practice Address - Country:US
Practice Address - Phone:801-253-4001
Practice Address - Fax:801-253-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5354110-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT079585401001Medicaid
UTH49473Medicare UPIN
UT079585401001Medicaid