Provider Demographics
NPI:1790149169
Name:PETERSEN, MADISON (MD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:PLASH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5019
Mailing Address - Country:US
Mailing Address - Phone:251-463-7082
Mailing Address - Fax:
Practice Address - Street 1:2451 FILLINGIM ST.
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-463-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL390200000X
AL41387207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program