Basic Information
| Provider Information | |||||||||
| NPI: | 1730132820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30382 | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591070382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888438475 | ||||||||
| FaxNumber: | 3148496395 | ||||||||
| Practice Location | |||||||||
| Address1: | 2827 FORT MISSOULA ROAD | ||||||||
| Address2: | COMMUNITY MEDICAL CENTER, DEPT. OF PATHOLOGY | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598047408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063274330 | ||||||||
| FaxNumber: | 4063274515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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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 | 207ZP0102X | 9730 | MT | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0036584 | 05 | MT | MEDICAID |