Basic Information
| Provider Information | |||||||||
| NPI: | 1881744167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 EOFF ST | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042348663 | ||||||||
| FaxNumber: | 3042348960 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 N 5TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | MARTINS FERRY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439351582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406336573 | ||||||||
| FaxNumber: | 7406336574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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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 | 208600000X | 13832 | WV | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 35078810 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0124384000 | 05 | WV | MEDICAID | 2262108 | 05 | OH | MEDICAID |