# LAURIS J. PETERSEN MD PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** GLENRIDGE FAMILY MEDICINE
- **Organization subpart:** No

## Provider details

- **NPI number:** 1659563989
- **Authorized official:** DR. LAURIS JON PETERSEN MD (CEO/PRESIDENT)
- **Authorized official phone:** (518) 399-0909

## Contact information

- **Practice address:** 15 GLENRIDGE RD, GLENVILLE, NY 12302-4520
- **Practice address phone:** (518) 399-0909
- **Practice address fax:** (518) 399-2640
- **Mailing address:** 15 GLENRIDGE RD, GLENVILLE, NY 12302-4520
- **Mailing address phone:** (518) 399-0909
- **Mailing address fax:** (518) 399-2640

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 213320 | NY | Yes |

## Other

- **Enumeration date:** 08/10/2007
- **Last updated:** 08/10/2007