Provider Demographics
NPI:1205874385
Name:PETERSEN, STEVE ALAN (MD)
Entity type:Individual
Prefix:
First Name:STEVE
Middle Name:ALAN
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 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:SMYTH BLDG, SUITE G-1
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2945
Mailing Address - Country:US
Mailing Address - Phone:443-444-4740
Mailing Address - Fax:443-444-4752
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:SMYTH BLDG, SUITE G-1
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2945
Practice Address - Country:US
Practice Address - Phone:443-444-4740
Practice Address - Fax:443-444-4752
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065131207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD012124000Medicaid
MDKR59P037Medicare PIN
MD012124000Medicaid