Basic Information
| Provider Information | |||||||||
| NPI: | 1508832809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 PETERSON PKWY | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562737823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3203542222 | ||||||||
| FaxNumber: | 3203542274 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 PETERSON PKWY | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562737823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3203542222 | ||||||||
| FaxNumber: | 3203542274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30171 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 262890200 | 05 | MN | MEDICAID |