Basic Information
| Provider Information | |||||||||
| NPI: | 1376592840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 744 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002421131 | ||||||||
| FaxNumber: | 5177874146 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 01/27/2010 | ||||||||
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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 | 174400000X | 02002148A | IN | Y | Other Service Providers | Specialist |
No ID Information.