Provider Demographics
NPI:1417901422
Name:PETERSON, BOYD M (DC)
Entity Type:Individual
Prefix:MS
First Name:BOYD
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:SPINE CARE CLINIC AT PLANK ROAD
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3421
Mailing Address - Country:US
Mailing Address - Phone:414-955-7199
Mailing Address - Fax:414-955-0110
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:SPINE CARE CLINIC AT PLANK ROAD
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3421
Practice Address - Country:US
Practice Address - Phone:414-955-7199
Practice Address - Fax:414-955-0110
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
007000261FOtherHUMANA
WI1417901422Medicaid
U31218Medicare UPIN
WI0003 75-390Medicare PIN
WI0273 68-086Medicare PIN