Provider Demographics
NPI:1184112344
Name:PETERSEN, MAX CHRISTIAN (MD)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:CHRISTIAN
Last Name:PETERSEN
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-3500
Mailing Address - Fax:314-230-1119
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV IM ENDOCRINOLOGY, STE 13B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-3500
Practice Address - Fax:314-230-1119
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020015426207QG0300X, 207R00000X, 208M00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200086114Medicaid