1538480223 NPI number — DR. STEPHANIE LYNN PETERSON M.D.

Table of content: DR. STEPHANIE LYNN PETERSON M.D. (NPI 1538480223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538480223 NPI number — DR. STEPHANIE LYNN PETERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
STEPHANIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538480223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10020 PROFESSIONAL CENTER DRIVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-231-0252
Provider Business Mailing Address Fax Number:
810-231-0256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10020 PROFESSIONAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
HAMBURG
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-231-0252
Provider Business Practice Location Address Fax Number:
810-231-0256
Provider Enumeration Date:
06/16/2010

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: 207R00000X , with the licence number:  1805043 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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