Basic Information
| Provider Information | |||||||||
| NPI: | 1902899057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 TECHNOLOGY DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117334068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312468289 | ||||||||
| FaxNumber: | 6312468294 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 TECHNOLOGY DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117334068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312468289 | ||||||||
| FaxNumber: | 6312468294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 175936 | NY | N | Other Service Providers | Specialist | 2086S0129X | 175936 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2C4298 | 01 | NY | HEALTHNET | OTHER | 0714028004 | 01 | NY | CIGNA HEALTHCARE | OTHER | 990015026 | 01 | NY | RR MEDICARE | OTHER | S500051 | 01 | NY | SUFFOLK HEALTH PLANS | OTHER | 11347567803 | 01 | NY | 1199 BENEFIT FUND | OTHER | 2110430 | 01 | NM | AETNA HEALTH PLANS | OTHER | CS1072 | 01 | NY | OXFORD HEALTH PLANS | OTHER | 1261940 | 01 | NY | UNITED HEALTHCARE | OTHER | GHI PPO CBP | 01 | NM | 0103702 | OTHER |