Provider Demographics
NPI:1881744167
Name:PETERSEN, JOSEPH MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
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 1:2000 EOFF ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3823
Mailing Address - Country:US
Mailing Address - Phone:304-234-8663
Mailing Address - Fax:304-234-8960
Practice Address - Street 1:222 N 5TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:MARTINS FERRY
Practice Address - State:OH
Practice Address - Zip Code:43935-1582
Practice Address - Country:US
Practice Address - Phone:740-633-6573
Practice Address - Fax:740-633-6574
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13832208600000X
OH35078810208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0124384000Medicaid
OH2262108Medicaid
A72519Medicare UPIN
OH0600827Medicare PIN
OH2262108Medicaid