Provider Demographics
NPI:1538243779
Name:PETERSON, KEVIN A (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:651-772-3461
Mailing Address - Fax:
Practice Address - Street 1:2001 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-638-0700
Practice Address - Fax:612-627-4205
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55D00PEOtherBLUE CROSS BLUE SHIELD
MN267390800Medicaid
MNHP16946OtherHEALTH PARTNERS
MN01-00482OtherMEDICA CHOICE
MN768302OtherARAZ
MN1008691OtherPREFERRED ONE
MN102872OtherUCARE
MN55D00PEOtherBLUE CROSS BLUE SHIELD