Provider Demographics
NPI:1669662532
Name:BRIAN R PETERSON MD PC
Entity Type:Organization
Organization Name:BRIAN R PETERSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-566-8304
Mailing Address - Street 1:3584 W 9000 S
Mailing Address - Street 2:SUITE 311
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4775
Mailing Address - Country:US
Mailing Address - Phone:801-566-8304
Mailing Address - Fax:801-566-8330
Practice Address - Street 1:3584 W 9000 S
Practice Address - Street 2:SUITE 311
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4775
Practice Address - Country:US
Practice Address - Phone:801-566-8304
Practice Address - Fax:801-566-8330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3139741205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty