Basic Information
| Provider Information | |||||||||
| NPI: | 1326000241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | GAY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 SOUTH SIBLEY AVE | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | LITCHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206933233 | ||||||||
| FaxNumber: | 3206933290 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SOUTH SIBLEY AVE | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | LITCHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206933233 | ||||||||
| FaxNumber: | 3206933290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31696 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 736868200 | 05 | MN | MEDICAID |