Provider Demographics
NPI:1356339303
Name:PETERSON, HOLLY CHRISTINE (MD, SFHM)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:CHRISTINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD, SFHM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRA CARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRA CARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44593207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110008471OtherMEDICARE
142118OtherU-CARE
951364OtherARAZ GROUP/AMERICA'S PPO
MN314780100Medicaid
59G88PEOtherBLUE CROSS BLUE SHIELD
1030668OtherPREFERRED ONE
HP35318OtherHEALTH PARTNERS
0404508OtherMEDICA HEALTH PLANS
2116659OtherFIRST HEALTH PLAN
314780100OtherMEDICAL ASSISTANCE (MA)
0404508OtherMEDICA HEALTH PLANS
142118OtherU-CARE