Provider Demographics
NPI:1972615474
Name:PETERSEN, RUSSELL S (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
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 1:3340 NORTH CENTER ST #800
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:5121 S COTTONWOOD STREET
Practice Address - Street 2:INTERMOUNTAIN MEDICAL CENTER
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84157
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT91-184977-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1502954OtherUMWA
UTPRA04891OtherMOLINA
UT73574OtherPEHP
UTQM0000075886OtherALTIUS
NV002086882Medicaid
UT2090168OtherUNITED HEALTHCARE
UT756601OtherDESERET MUTUAL
WY112774800Medicaid
UT107006198101OtherIHC
ID804075500Medicaid
AZ840935Medicaid
UT53263OtherHEALTHY U
UT538587317OtherMAILHANDLERS
UT870545614PE1OtherEDUCATORS MUTUAL
UT870545614PE1OtherEDUCATORS MUTUAL
ID804075500Medicaid
WY112774800Medicaid