Basic Information
| Provider Information | |||||||||
| NPI: | 1245238104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | B | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27688 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015341360 | ||||||||
| FaxNumber: | 8013669883 | ||||||||
| Practice Location | |||||||||
| Address1: | 3838 S 700 E | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841061466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012614988 | ||||||||
| FaxNumber: | 8012699427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 1748333-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 08517 | 05 | UT | MEDICAID |