Provider Demographics
NPI:1790956514
Name:JOSEPH R. PETERSEN, M.D.
Entity Type:Organization
Organization Name:JOSEPH R. PETERSEN, M.D.
Other - Org Name:ORTHOPEDIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:208-678-1138
Mailing Address - Street 1:1344 HILAND AVE STE A
Mailing Address - Street 2:P. O. BOX 1263
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1564
Mailing Address - Country:US
Mailing Address - Phone:208-678-1138
Mailing Address - Fax:208-678-5833
Practice Address - Street 1:1344 HILAND AVE STE A
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-678-1138
Practice Address - Fax:208-678-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5283174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1225105604OtherNPI INDIV
IDC36979Medicare UPIN
ID1119681Medicare PIN
ID1374841Medicare PIN