Basic Information
| Provider Information | |||||||||
| NPI: | 1912017104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7702 N ALPINE RD | ||||||||
| Address2: | |||||||||
| City: | LOVES PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611113107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
| FaxNumber: | 8159719266 | ||||||||
| Practice Location | |||||||||
| Address1: | 7702 N ALPINE RD | ||||||||
| Address2: | |||||||||
| City: | LOVES PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611113107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159712000 | ||||||||
| FaxNumber: | 8159719266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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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 | 207R00000X | 036-072554 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036072554 | 05 | IL | MEDICAID |