NPIMap

Organization Active NPI

David S. Petersen, M.D.S.C.

  • Urology Physician
  • Moline, IL
National Provider Identifier
1982900825
Registry record updated Feb 9, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urology PhysicianTaxonomy code 208800000X
License
036-055984 Issued in IL
Legal business name
DAVID S. PETERSEN, M.D.S.C.
Practice address
2121 1St Street a
Moline, IL 61265-7745
Phone
(309) 764-9790
Fax
(309) 764-9632
NPI assigned
Feb 9, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2011

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

Authorized official

Name
Dr. David S Petersen, M.D.
Title
President
Phone
(309) 764-9790

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Urology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208800000X 036-055984 IL Primary

Addresses

Primary practice location

2121 1St Street a
Moline, IL 61265-7745

Mailing address

2121 1St Street a
Moline, IL 61265-7745
Phone (309) 764-9790

Other identifiers 1

IdentifierTypeStateIssuer
036055984MedicaidIL

National Provider Directory

National Provider Directory

Locations

2121 1st Street a
Moline, IL 61265
Phone (309) 764-9790

NPI Registry JSON

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

{
    "created_epoch": "1297209600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1297209600000",
    "number": "1982900825",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2121 1ST STREET A",
            "city": "MOLINE",
            "state": "IL",
            "postal_code": "612657745",
            "telephone_number": "309-764-9790",
            "fax_number": "309-764-9632"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2121 1ST STREET A",
            "city": "MOLINE",
            "state": "IL",
            "postal_code": "612657745",
            "telephone_number": "309-764-9790",
            "fax_number": "309-764-9632"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DAVID S. PETERSEN, M.D.S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-09",
        "last_updated": "2011-02-09",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "309-764-9790",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "208800000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Urology",
            "state": "IL",
            "license": "036-055984",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036055984",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Moline, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2011; 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.