1629058904 NPI number — DR. GAIL PETERSON PH.D.

Table of content: DR. GAIL PETERSON PH.D. (NPI 1629058904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629058904 NPI number — DR. GAIL PETERSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
GAIL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1629058904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 443
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62903-0443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-529-4988
Provider Business Mailing Address Fax Number:
618-351-1419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 N WOOD RD
Provider Second Line Business Practice Location Address:
MILWOOD EXECUTIVE SUITES
Provider Business Practice Location Address City Name:
MURPHYSBORO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62966-6290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-529-4988
Provider Business Practice Location Address Fax Number:
618-351-1419
Provider Enumeration Date:
01/20/2006

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: 103TB0200X , with the licence number:  071-002561 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TB0200X , with the licence number: 2006006592 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 27485 . This is a "HEALTH ALLIANCE MEDICAL PLANS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 03972011 . This is a "BLUE CROSS/ BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 126480 . This is a "HEALTHLINK PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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