Provider Demographics
NPI:1063535706
Name:ROBERT L. PETERSON, M.D., S.C.
Entity type:Organization
Organization Name:ROBERT L. PETERSON, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-258-8898
Mailing Address - Street 1:900 RIVERSIDE DR
Mailing Address - Street 2:SUITE III
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1983
Mailing Address - Country:US
Mailing Address - Phone:715-258-8898
Mailing Address - Fax:715-258-6980
Practice Address - Street 1:900 RIVERSIDE DR
Practice Address - Street 2:SUITE III
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1983
Practice Address - Country:US
Practice Address - Phone:715-258-8898
Practice Address - Fax:715-258-6980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty