1225105604 NPI number — DR. JOSEPH R PETERSEN

Table of content: DR. JOSEPH R PETERSEN (NPI 1225105604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225105604 NPI number — DR. JOSEPH R PETERSEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
JOSEPH
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSEN
Provider Other First Name:
JOSEPH
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1225105604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1344 HILAND AVE STE A
Provider Second Line Business Mailing Address:
P. O. BOX 1263
Provider Business Mailing Address City Name:
BURLEY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83318-1564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-678-1138
Provider Business Mailing Address Fax Number:
208-678-5833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1344 HILAND AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83318-1564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-1138
Provider Business Practice Location Address Fax Number:
208-678-5833
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  M5283 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000010003563 . This is a "BLUE SHIELD PROVIDER NO." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: C36979 . This is a "DMBA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 014917 . This is a "SELECTCARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: I000490 . This is a "TRICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 74096 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0791870001 . This is a "MEDICARE DMERC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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