# JOSEPH R. PETERSEN, M.D.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Orthopedic Surgery Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1790956514
- **Authorized official:** DR. JOSEPH R PETERSEN I M.D. (PHYSICIAN/OWNER)
- **Authorized official phone:** (208) 678-1138

## Contact information

- **Practice address:** 1344 HILAND AVE STE A, BURLEY, ID 83318-1564
- **Practice address phone:** (208) 678-1138
- **Practice address fax:** (208) 678-5833
- **Mailing address:** 1344 HILAND AVE STE A, P. O. BOX 1263, BURLEY, ID 83318-1564
- **Mailing address phone:** (208) 678-1138
- **Mailing address fax:** (208) 678-5833

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | M5283 | ID | Yes |

## Other

- **Enumeration date:** 03/19/2008
- **Last updated:** 03/19/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1225105604 | NPI INDIV | — |