Provider Demographics
NPI:1821108010
Name:PETERSON, BRUCE P (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:P
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 1:5000 PRAIRIE ROSE DR
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7792
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:
Practice Address - Street 1:5000 PRAIRIE ROSE DR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7792
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-053478208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053478Medicaid
IL036053478Medicaid
IL933580Medicare PIN