Provider Demographics
NPI:1477510915
Name:PETERSEN, BENDT P III (MD)
Entity Type:Individual
Prefix:MR
First Name:BENDT
Middle Name:P
Last Name:PETERSEN
Suffix:III
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 1:6701 AIRPORT BLVD
Mailing Address - Street 2:BUILDING D SUITE 100
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608
Mailing Address - Country:US
Mailing Address - Phone:251-607-6117
Mailing Address - Fax:251-219-0746
Practice Address - Street 1:6701 AIRPORT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6701
Practice Address - Country:US
Practice Address - Phone:251-607-6117
Practice Address - Fax:251-219-0746
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00016728207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL512-30874OtherBCBS
AL249129Medicaid
AL051512177OtherBCBS
AL051512177Medicaid
631187140OtherTAX ID
AL051512177OtherBCBS
AL000098916Medicare ID - Type Unspecified