Provider Demographics
NPI:1245957737
Name:PETERSEN CONCIERGE MEDICAL
Entity type:Organization
Organization Name:PETERSEN CONCIERGE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:ESTHER
Authorized Official - Last Name:JUHL PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-541-7040
Mailing Address - Street 1:2315 MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7342
Mailing Address - Country:US
Mailing Address - Phone:406-499-1354
Mailing Address - Fax:406-830-3123
Practice Address - Street 1:2315 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7342
Practice Address - Country:US
Practice Address - Phone:406-541-7040
Practice Address - Fax:406-830-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty