Joseph R Petersen

Primary specialty

SpecialistTaxonomy code 174400000X

License

M5283 Issued in ID

Practice address

1344 Hiland Ave Ste a
Burley, ID 83318-1564

Phone

(208) 678-1138

Fax

(208) 678-5833

NPI assigned

Nov 29, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 6

Other names 1

• Dr. Joseph Petersen Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Ambulatory Surgery Center of Burley, LLC

  • Ambulatory Surgical Clinic/Center
  • Burley, ID
  • NPI 1992706840
  NPD (past) Authorized official
• Joseph R. Petersen, M.D.

  • Durable Medical Equipment & Medical Supplies
  • Burley, ID
  • NPI 1154744407
  NPD (past) Authorized official
• Joseph R. Petersen, M.D.

  dba Orthopedic Surgery Center

  • Specialist
  • Burley, ID
  • NPI 1790956514
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164758400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1225105604",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1344 HILAND AVE STE A",
            "address_2": "P. O. BOX 1263",
            "city": "BURLEY",
            "state": "ID",
            "postal_code": "833181564",
            "telephone_number": "208-678-1138",
            "fax_number": "208-678-5833"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1344 HILAND AVE STE A",
            "city": "BURLEY",
            "state": "ID",
            "postal_code": "833181564",
            "telephone_number": "208-678-1138",
            "fax_number": "208-678-5833"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "JOSEPH",
        "middle_name": "R",
        "name_prefix": "Dr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-11-29",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "ID",
            "license": "M5283",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD PROVIDER NO.",
            "identifier": "000010003563",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DMBA",
            "identifier": "C36979",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SELECTCARE",
            "identifier": "014917",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TRICARE",
            "identifier": "I000490",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS PROVIDER NUMBE",
            "identifier": "74096",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE DMERC",
            "identifier": "0791870001",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JOSEPH",
            "last_name": "PETERSEN",
            "prefix": "DR.",
            "credential": "M.D.",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Pain & Spine Consultants
• Jason Oneal Parkinson, D.O.
• Pathways, Inc
• Temp Ray Patterson, MD
• Micalena Rose Perkins, MSN, APRN, CPNP
• Tayne Peterson
• Deb Phillips, PHARMD
• Alan Scott Pickup, DMD
• Eric B Pierce, O.D.
• Brek Pilling, PHD

• Specialist in Burley, ID
• Providers in Burley, ID by specialty
• Specialist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.