Basic Information
| Provider Information | |||||||||
| NPI: | 1912986555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 56765 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900746765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063860 | ||||||||
| FaxNumber: | 6024066132 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063157 | ||||||||
| FaxNumber: | 6024064113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 07/19/2012 | ||||||||
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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 | 14414 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 14414 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 14414 | AZ | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 231720 | 05 | AZ | MEDICAID |