Provider Demographics
NPI:1649250242
Name:PETERSON, SCOTT M (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:3300 W CENTRE AVE
Practice Address - Street 2:BRONSON OB GYN ASSOCIATES
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4666
Practice Address - Country:US
Practice Address - Phone:269-327-2211
Practice Address - Fax:269-327-0273
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-11-27
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301068138207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4770173Medicaid
MI1235131137OtherBCBSM - BLH
MI4681190Medicaid
MI1649250242Medicaid
MI1235131137OtherBCBSM - BLH
MI4681190Medicaid
MI4770173Medicaid
MIM20520040Medicare PIN
MIC98618094Medicare PIN