Provider Demographics
NPI:1841388105
Name:PETERSON, THOMAS M (PT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4479 FARMDALE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTA
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9273
Mailing Address - Country:US
Mailing Address - Phone:320-248-8696
Mailing Address - Fax:
Practice Address - Street 1:2835 W SAINT GERMAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6281
Practice Address - Country:US
Practice Address - Phone:320-259-4151
Practice Address - Fax:320-259-5707
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN982345000Medicaid
MN6428763OtherMEDICA AND SELECT CARE
MN650022803OtherRAILROAD MEDICARE
MNHP 24500OtherHEALTH PARTNERS
MN1D114PEOtherBLUE CROSS BLUE SHIELD