Petersen Neurospine, PLLC

Business Information

Division Name	PETERSEN NEUROSPINE
Congressional District	01
State/Country of Incorporation	AL, USA
Activation Date	2024-02-26
Initial Registration Date	2024-02-20
Entity Start Date	2019-09-01
Fiscal Year End Close Date	Dec 31

Points of Contacts

Electronic Business
Title	PRIMARY POC
Name	KRISTA GRILLS
Role	BILLING
Address	6701 AIRPORT BLVD STE D-100, MOBILE, AL, 36608, USA

Government Business
Title	PRIMARY POC
Name	SARA COTTRELL
Role	OFFICE COORDINATOR
Address	6701 AIRPORT BLVD, BUILDING D SUITE 100, MOBILE, AL, 36608, USA

Past Performance	Information not Available

Contacts

Phone	+1 251-607-6117
Fax	2512190746

Authorized person

Name	BENDT P PETERSEN III
Role	PHYSICIAN
Phone	2516076117

Taxonomy

Taxonomy Code	207XS0117X - Orthopaedic Surgery of the Spine Physician
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	248545
State	AL

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2024-10-13
Name of individual signing	BENDT P. PETERSEN, III
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2024-10-14
Name of individual signing	BENDT P. PETERSEN, III
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2023-10-11
Name of individual signing	BENDT P. PETERSEN, III

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2023-10-11
Name of individual signing	BENDT P. PETERSEN, III

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2022-04-15
Name of individual signing	BENDT P. PETERSEN, III

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2022-04-15
Name of individual signing	BENDT P. PETERSEN, III

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2021-07-29
Name of individual signing	BENDT P. PETERSEN, III

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2020-01-01
Business code	621111
Sponsor’s telephone number	2516076117
Plan sponsor’s address	6701 AIRPORT BLVD, D100, MOBILE, AL, 36608

Signature of

Role	Plan administrator
Date	2021-07-26
Name of individual signing	BENDT P. PETERSEN, III