1366554784 NPI number — MARK M PETERS M.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366554784 NPI number — MARK M PETERS M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERS
Provider First Name:
MARK
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
M

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:
1366554784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 BRYAN ST
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
HUNTINGDON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16652-2413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-643-6300
Provider Business Mailing Address Fax Number:
814-643-8776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 BRYAN ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
HUNTINGDON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16652-2413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-643-6300
Provider Business Practice Location Address Fax Number:
814-643-8776
Provider Enumeration Date:
08/31/2006

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: 103TA0400X , with the licence number:  PS008155L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TB0200X , with the licence number: PS008155L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TC1900X , with the licence number: PS008155L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TF0000X , with the licence number: PS008155L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103T00000X , with the licence number: PS008155L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 401131 . This is a "BLUE SHIELD (MANAGED CARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1365219 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 207627 . This is a "VALUE OPTIONS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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