Provider Demographics
NPI:1912017104
Name:PETERSEN, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:PETERSEN
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 1:7702 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3107
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-971-9266
Practice Address - Street 1:7701 W ASPERA BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7947
Practice Address - Country:US
Practice Address - Phone:623-465-6060
Practice Address - Fax:623-242-5833
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072554Medicaid
IL036072554Medicaid
ILD16127Medicare UPIN