Basic Information
| Provider Information | |||||||||
| NPI: | 1205874385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | STEVE | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 LOCH RAVEN BLVD | ||||||||
| Address2: | SMYTH BLDG, SUITE G-1 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212392945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434444740 | ||||||||
| FaxNumber: | 4434444752 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 LOCH RAVEN BLVD | ||||||||
| Address2: | SMYTH BLDG, SUITE G-1 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212392945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434444740 | ||||||||
| FaxNumber: | 4434444752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | D0065131 | MD | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 012124000 | 05 | MD | MEDICAID |