Provider Demographics
NPI:1417904384
Name:PETERSON, CHRISTIAN M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 TIMBER RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-8600
Mailing Address - Country:US
Mailing Address - Phone:218-444-9668
Mailing Address - Fax:
Practice Address - Street 1:4211 MINNKOTA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-6078
Practice Address - Country:US
Practice Address - Phone:218-444-6127
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA01753Medicare UPIN