Provider Demographics
NPI:1477395184
Name:BRIAN PETERSON ORTHOPEDICS, PLLC
Entity type:Organization
Organization Name:BRIAN PETERSON ORTHOPEDICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-234-6728
Mailing Address - Street 1:2370 ANSELMO DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-7106
Mailing Address - Country:US
Mailing Address - Phone:951-736-0137
Mailing Address - Fax:
Practice Address - Street 1:120 FRANK MARTIN RD STE 200
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-7102
Practice Address - Country:US
Practice Address - Phone:931-841-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty