Provider Demographics
NPI:1285745711
Name:PETERSON, MATTHEW R (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 DEL RIO CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3181
Mailing Address - Country:US
Mailing Address - Phone:847-691-3958
Mailing Address - Fax:
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002763207P00000X
MO2008025807363A00000X
IL85-002763363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1072542OtherPHYSICIAN ASSISTANT CERTI
1072542OtherPHYSICIAN ASSISTANT CERTI
ILIL1682019Medicare PIN
IL567730014Medicare PIN
IL567730007Medicare PIN
ILIL1682052Medicare PIN
ILK31054Medicare PIN
ILK31055Medicare PIN