Active NPI
Tim Petersen
- Driver
- Fairview, IL
National Provider Identifier
1689113680
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Driver
- License
- P362-8106-6065
- Practice address
- 32059 N State Route 97
Fairview, IL 61432-9643 - Phone
- (309) 414-2155
- NPI assigned
- Feb 23, 2017
- 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 |
|---|---|---|---|---|
| Driver | 172A00000X | P362-8106-6065 | IL | Primary |
Addresses
Primary practice location
32059 N State Route 97
Fairview, IL 61432-9643
Mailing address
32059 N State Route 97
Fairview, IL 61432-9643
Phone (309) 414-2155
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)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| P362-8106-6065 | IL | MD | Driver |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1487808000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1487808000000",
"number": "1689113680",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "32059 N STATE ROUTE 97",
"city": "FAIRVIEW",
"state": "IL",
"postal_code": "614329643",
"telephone_number": "309-414-2155"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "32059 N STATE ROUTE 97",
"city": "FAIRVIEW",
"state": "IL",
"postal_code": "614329643",
"telephone_number": "309-414-2155"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "TIM",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-02-23",
"last_updated": "2017-02-23",
"status": "A"
},
"taxonomies": [
{
"code": "172A00000X",
"taxonomy_group": "",
"desc": "Driver",
"state": "IL",
"license": "P362-8106-6065",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fairview, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 23, 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.