Provider Demographics
NPI:1316461718
Name:J MICHAEL PETERSEN
Entity type:Organization
Organization Name:J MICHAEL PETERSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-233-2455
Mailing Address - Street 1:109 MOUNT WOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2632
Mailing Address - Country:US
Mailing Address - Phone:304-233-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:2000 EOFF ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3823
Practice Address - Country:US
Practice Address - Phone:304-233-2455
Practice Address - Fax:304-233-6073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13832208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty