Individual
DR. LAURIS J PETERSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
15 GLENRIDGE RD, GLENVILLE, NY 12302-4520
(518) 399-0909
(518) 399-2640
Mailing address
5 MONARDA DR, SCOTIA, NY 12302-4202
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
213320
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000491234003
BLUE SHIELD OF NENY
NY
01
—
10031080
CDPHP
NY
01
—
714547
MVP
NY
01
—
76V271
EMPIRE BLUE
NY
01
—
P00315575
RAILROAD MEDICARE
NY
Enumeration date
10/25/2006
Last updated
07/08/2007
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