Provider Demographics
NPI:1548465750
Name:CHARLES S PETERSON MD PC
Entity type:Organization
Organization Name:CHARLES S PETERSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-558-3744
Mailing Address - Street 1:PO BOX 2507
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85214-2507
Mailing Address - Country:US
Mailing Address - Phone:480-558-3744
Mailing Address - Fax:480-558-3801
Practice Address - Street 1:5111 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-7075
Practice Address - Country:US
Practice Address - Phone:480-558-3744
Practice Address - Fax:480-558-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28027207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ102027Medicare UPIN