Phillip H Petersen, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

M5405 Issued in ID

Practice address

301 Cedar St
Orofino, ID 83544-9029

Phone

(208) 476-4555

Fax

(208) 476-5385

NPI assigned

Jun 14, 2005

Last updated

Dec 19, 2017By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

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

{
    "created_epoch": "1118707200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1513641600000",
    "number": "1295730661",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "301 CEDAR ST",
            "city": "OROFINO",
            "state": "ID",
            "postal_code": "835449029",
            "telephone_number": "208-476-4555",
            "fax_number": "208-476-5385"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 CEDAR ST",
            "city": "OROFINO",
            "state": "ID",
            "postal_code": "835449029",
            "telephone_number": "208-476-4555",
            "fax_number": "208-476-5385"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "PHILLIP",
        "middle_name": "H",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-06-14",
        "last_updated": "2017-12-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "M5405",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003883100",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Orofino Chiropractic, PLLC (Orofino Spine Center)
• Orofino Physical Therapy and Wellness Inc
• Orofino Physical Therapy, PLLC
• Orofino Retirement Properties Inc (Brookside Landing)
• Owc, Inc. (Orofino Wellness Center)
• Patricia Peterson, R.PH.
• Ashley Marie Pomponio
• Damon Josef Popovics, DC
• Bridgette Presnell
• Suzi M Quintal, LMSW

• Family Medicine Physician in Orofino, ID
• Providers in Orofino, ID by specialty
• Family Medicine Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2017; 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.