Provider Demographics
NPI:1730132820
Name:PETERSON, BRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:
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:PO BOX 30382
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-0382
Mailing Address - Country:US
Mailing Address - Phone:888-843-8475
Mailing Address - Fax:314-849-6395
Practice Address - Street 1:2827 FORT MISSOULA ROAD
Practice Address - Street 2:COMMUNITY MEDICAL CENTER, DEPT. OF PATHOLOGY
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7408
Practice Address - Country:US
Practice Address - Phone:406-327-4330
Practice Address - Fax:406-327-4515
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9730207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0036584Medicaid
H38868Medicare UPIN
MT000082010Medicare ID - Type Unspecified