Provider Demographics
NPI:1912991290
Name:PETERSEN, BRENT H (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:H
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:350 SURRYSE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1345 RYAN PKWY
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-4530
Practice Address - Country:US
Practice Address - Phone:847-658-9555
Practice Address - Fax:847-658-2167
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036075837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine