1225175607 NPI number — AMBER M PETERSON MD

Table of content: AMBER M PETERSON MD (NPI 1225175607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225175607 NPI number — AMBER M PETERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
AMBER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225175607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2695 ROCKY MOUNTAIN AVE STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80538-9071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8890 N UNION BLVD STE 170
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80920-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-364-5005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2007

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: 207Q00000X , with the licence number:  036116852 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: DR.0056063 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 475790YKRD . This is a "MEDICARE NUMBER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 21180075 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com