Provider Demographics
NPI:1427026913
Name:PETERSON, GLENN R (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
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 1:9301 PARKWEST BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923
Mailing Address - Country:US
Mailing Address - Phone:865-694-9391
Mailing Address - Fax:865-694-7780
Practice Address - Street 1:9301 PARKWEST BOULEVARD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923
Practice Address - Country:US
Practice Address - Phone:865-694-9391
Practice Address - Fax:865-694-7780
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN175192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3022828Medicare ID - Type Unspecified
A98674Medicare UPIN