Provider Demographics
NPI:1386737674
Name:PETERSON, CHERYL S (MD)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:S
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 1:2797 PRAIRIE AVE
Mailing Address - Street 2:SUITE 26
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2288
Mailing Address - Country:US
Mailing Address - Phone:815-714-8030
Mailing Address - Fax:
Practice Address - Street 1:2797 PRAIRIE AVE
Practice Address - Street 2:SUITE 26
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2288
Practice Address - Country:US
Practice Address - Phone:815-714-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-080979207Q00000X
WI31236020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL553180OtherMEDICARE GROUP #
WI31600400Medicaid
IL834340OtherMEDICARE GROUP #
WI31600400Medicaid
IL553180OtherMEDICARE GROUP #
IL834340008Medicare PIN
IL553180OtherMEDICARE GROUP #