Provider Demographics
NPI:1609079094
Name:PETERSON, MICHAEL GENE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GENE
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 1:5435 FELTL RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7983
Mailing Address - Country:US
Mailing Address - Phone:952-857-1504
Mailing Address - Fax:
Practice Address - Street 1:201 E. NICOLLET BLVD.
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:612-889-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085530207P00000X
MN52328207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1609079094Medicaid
MN52328OtherMN MEDICAL LICENSE
207P00000XOtherPROVIDER TAXONOMY
207P00000XOtherPROVIDER TAXONOMY