Active NPI
Jerald Miles Petersen, MD
- Hospitalist Physician
- Mount Horeb, WI
National Provider Identifier
1649209032
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Hospitalist Physician
- License
- 64866
- Practice address
- 1275 Lindokken Rd Ste 315
Mount Horeb, WI 53572-9701 - Phone
- (000) 000-0000
- NPI assigned
- Jun 30, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Hospitalist Physician | 208M00000X | 64866 | WI | Primary |
Addresses
Primary practice location
1275 Lindokken Rd Ste 315
Mount Horeb, WI 53572-9701
Mailing address
1275 Lindokken Rd
Mount Horeb, WI 53572-9701
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 732880000 | Medicaid | MN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 64866 | WI | MD | Hospitalist Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1151625600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1644710400000",
"number": "1649209032",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1275 LINDOKKEN RD",
"city": "MOUNT HOREB",
"state": "WI",
"postal_code": "535729701"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1275 LINDOKKEN RD STE 315",
"city": "MOUNT HOREB",
"state": "WI",
"postal_code": "535729701",
"telephone_number": "000-000-0000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "JERALD",
"middle_name": "MILES",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-06-30",
"last_updated": "2022-02-13",
"certification_date": "2022-02-13",
"status": "A"
},
"taxonomies": [
{
"code": "208M00000X",
"taxonomy_group": "",
"desc": "Hospitalist",
"state": "WI",
"license": "64866",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "732880000",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Mount Horeb, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.