Provider Demographics
NPI:1548359243
Name:PETERSON, GREGORY J (DC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1537
Mailing Address - Country:US
Mailing Address - Phone:320-839-2323
Mailing Address - Fax:320-839-2323
Practice Address - Street 1:215 2ND ST SE
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1537
Practice Address - Country:US
Practice Address - Phone:320-839-2323
Practice Address - Fax:320-839-2323
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1992111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1B090PEOtherBCBS INDIVIDUAL PROVIDER
MN230676OtherACN PROVIDER NUMBER
MN7602140OtherSD MEDICAL ASSISTANCE
MN595727300Medicaid
MN030701023OtherPRIME WEST MED ASSISTANCE
MN350048036OtherRR MEDICARE
MN391886617OtherTRIAD
MN20341OtherSIOUX VALLEY HEALTH PLAN
MN49317PEOtherBCBS CLINIC/GROUP NUMBER
MN030701023OtherPRIME WEST MED ASSISTANCE
MN1B090PEOtherBCBS INDIVIDUAL PROVIDER