Provider Demographics
NPI:1558327064
Name:PETERSON, KEVIN P (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:720 WASHINGTON AVE SE, STE 200
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:612-676-8992
Practice Address - Street 1:1414 MARYLAND AVE E
Practice Address - Street 2:UMPHYSICIANS PHALEN VILLAGE CLINIC
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55106
Practice Address - Country:US
Practice Address - Phone:651-772-3461
Practice Address - Fax:651-772-5477
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2013-02-07
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Provider Licenses
StateLicense IDTaxonomies
MN27012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95991Medicare UPIN