Provider Demographics
NPI:1801017843
Name:PETERSON, ROBERT G (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25421 RIVERVIEW
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375
Mailing Address - Country:US
Mailing Address - Phone:248-449-3069
Mailing Address - Fax:
Practice Address - Street 1:24360 NOVI RD
Practice Address - Street 2:B-1
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2404
Practice Address - Country:US
Practice Address - Phone:248-449-4757
Practice Address - Fax:248-735-2446
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301006979OtherSTATE DC LICENSE
MIU76994Medicare UPIN
MIOM87600Medicare ID - Type Unspecified