Provider Demographics
NPI:1891293668
Name:PETERSEN MEDICAL CORP.
Entity Type:Organization
Organization Name:PETERSEN MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-846-9303
Mailing Address - Street 1:7235 CORAL WAY STE 213
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1452
Mailing Address - Country:US
Mailing Address - Phone:305-846-9303
Mailing Address - Fax:305-640-5705
Practice Address - Street 1:7235 CORAL WAY STE 213
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1452
Practice Address - Country:US
Practice Address - Phone:305-846-9303
Practice Address - Fax:305-640-5705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation