Provider Demographics
NPI:1528185303
Name:PETERSON, SOARIES MAXINE (PHD, MD)
Entity Type:Individual
Prefix:
First Name:SOARIES
Middle Name:MAXINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 PECK ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1428
Mailing Address - Country:US
Mailing Address - Phone:231-733-2500
Mailing Address - Fax:231-733-9899
Practice Address - Street 1:2301 PECK ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1428
Practice Address - Country:US
Practice Address - Phone:231-733-2500
Practice Address - Fax:231-733-9899
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3118944Medicaid
MI0M01850Medicare ID - Type Unspecified
MI3118944Medicaid