Basic Information
| Provider Information | |||||||||
| NPI: | 1356339436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | TUTT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1805 HENNEPIN AVE N | ||||||||
| Address2: | GLENCOE REGIONAL HEALTH SERVICES | ||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553361416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
| FaxNumber: | 3208647887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 HENNEPIN AVE N | ||||||||
| Address2: | GLENCOE REGIONAL HEALTH SERVICES | ||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553361416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
| FaxNumber: | 3208647887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39514 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 658217600 | 05 | MN | MEDICAID |