Basic Information
Provider Information | |||||||||
NPI: | 1609827781 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETERSON | ||||||||
FirstName: | RONALD | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 NICOLLET MALL | ||||||||
Address2: | SUITE 400 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554022500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6123332503 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 801 NICOLLET MALL | ||||||||
Address2: | SUITE 400 | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554022500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6123332503 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 23275 | MN | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 26399 | 01 | MN | AMERICA'S PPO | OTHER | 30400000 | 05 | WI |   | MEDICAID | FP9041001070 | 01 | MN | PREFERRED ONE | OTHER | 13724PE | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | HP14163 | 01 | MN | HEALTH PARTNERS | OTHER | 0700065 | 01 | MN | MEDICA DUAL/MEDICARE MA | OTHER | 0701452 | 01 | MN | MEDICA | OTHER | A004 | 01 | MN | TRICARE WEST/CHAMPUS | OTHER |