Basic Information
| Provider Information | |||||||||
| NPI: | 1104280700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | KYLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4215 BURNS RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616947776 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4215 BURNS RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616947776 | ||||||||
| FaxNumber: | 5616943099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2016 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | A171287 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207XS0117X | ME155351 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
No ID Information.