Provider Demographics
NPI:1336114966
Name:PETERSON, JEROME R (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MAIL STOP 33100A
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5463
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:8450 SEASONS PKWY
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4402
Practice Address - Country:US
Practice Address - Phone:612-339-3663
Practice Address - Fax:651-702-5305
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN19789207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A06972Medicare UPIN