Provider Demographics
NPI:1154744407
Name:JOSEPH R. PETERSEN, M.D.
Entity type:Organization
Organization Name:JOSEPH R. PETERSEN, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-678-1138
Mailing Address - Street 1:PO BOX 1263
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-0859
Mailing Address - Country:US
Mailing Address - Phone:208-678-1138
Mailing Address - Fax:208-678-5833
Practice Address - Street 1:1344 HILAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-678-1138
Practice Address - Fax:208-678-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1225105604Medicaid
ID1374841Medicare Oscar/Certification
ID119681Medicare PIN
ID0791870001Medicare NSC
C36979Medicare UPIN