Provider Demographics
NPI:1487632675
Name:PETERSEN, KATHLEEN B (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5739
Mailing Address - Country:US
Mailing Address - Phone:207-623-1322
Mailing Address - Fax:
Practice Address - Street 1:5 CALDWELL RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5739
Practice Address - Country:US
Practice Address - Phone:207-623-1322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012473207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME257240099Medicaid
ME005243OtherANTHEM
ME1041118OtherAETNA
ME6191075OtherCIGNA
MEB86469OtherHARVARD PILGRIM
ME1041118OtherAETNA
MEB86469OtherHARVARD PILGRIM