Provider Demographics
NPI:1982900825
Name:DAVID S. PETERSEN, M.D.S.C.
Entity Type:Organization
Organization Name:DAVID S. PETERSEN, M.D.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-764-9790
Mailing Address - Street 1:2121 1ST STREET A
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7745
Mailing Address - Country:US
Mailing Address - Phone:309-764-9790
Mailing Address - Fax:309-764-9632
Practice Address - Street 1:2121 1ST STREET A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7745
Practice Address - Country:US
Practice Address - Phone:309-764-9790
Practice Address - Fax:309-764-9632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-055984208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055984Medicaid
ILD09784Medicare UPIN
IL036055984Medicaid