Provider Demographics
NPI:1174762397
Name:PETERSON, BRIAN J (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7435 WEST TALCOTT AVENUE
Mailing Address - Street 2:RESURRECTION EMERGENCY MEDICINE RESIDENCY PROGRAM
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3746
Mailing Address - Country:US
Mailing Address - Phone:773-792-7921
Mailing Address - Fax:
Practice Address - Street 1:405 STAGELINE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7848
Practice Address - Country:US
Practice Address - Phone:715-531-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52859207P00000X
WI54360-21207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine