Provider Demographics
NPI:1932372182
Name:PETERSON, KIM B (HIS)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:B
Last Name:PETERSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 N 2ND ST
Mailing Address - Street 2:SUITE 213
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1818
Mailing Address - Country:US
Mailing Address - Phone:414-272-1466
Mailing Address - Fax:414-272-1467
Practice Address - Street 1:823 N 2ND ST
Practice Address - Street 2:SUITE 213
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1818
Practice Address - Country:US
Practice Address - Phone:414-272-1466
Practice Address - Fax:414-272-1467
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI187-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42820600Medicaid