Provider Demographics
NPI:1063417947
Name:PETERSON, MARGIE H (MD)
Entity type:Individual
Prefix:DR
First Name:MARGIE
Middle Name:H
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 GRIFFIN ST E
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001-1439
Mailing Address - Country:US
Mailing Address - Phone:715-268-8000
Mailing Address - Fax:715-268-0311
Practice Address - Street 1:265 GRIFFIN ST E
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1439
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:715-268-0311
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
160056073OtherPALMETTO GBA RR MEDICARE
WI30701000Medicaid
46Q71PEOtherBCBS MN
1016661OtherPREFERRED ONE
WI30701000Medicaid
WIB55712Medicare UPIN