Provider Demographics
NPI:1336238757
Name:PETERSON, MICHAEL E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:PETERSON
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 1:1000 W 4TH ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3730
Mailing Address - Country:US
Mailing Address - Phone:605-274-2178
Mailing Address - Fax:605-668-4404
Practice Address - Street 1:1115 W 9TH ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3310
Practice Address - Country:US
Practice Address - Phone:605-668-8850
Practice Address - Fax:605-668-9448
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD48262085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD236639OtherMIDLANDS CHOICE
SD7200512Medicaid
SD1580614OtherARAZ
SD4826OtherDAKOTACARE
SD01030622OtherPREFERRED ONE
SD1580614OtherARAZ
SD4826OtherDAKOTACARE
SDF34226Medicare UPIN
SD41419Medicare ID - Type Unspecified