Provider Demographics
NPI:1659563989
Name:LAURIS J. PETERSEN MD PC
Entity Type:Organization
Organization Name:LAURIS J. PETERSEN MD PC
Other - Org Name:GLENRIDGE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIS
Authorized Official - Middle Name:JON
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-399-0909
Mailing Address - Street 1:15 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4520
Mailing Address - Country:US
Mailing Address - Phone:518-399-0909
Mailing Address - Fax:518-399-2640
Practice Address - Street 1:15 GLENRIDGE RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-4520
Practice Address - Country:US
Practice Address - Phone:518-399-0909
Practice Address - Fax:518-399-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0100Medicare PIN