1972601508 NPI number — DR. MARTA J PETERSEN M.D.

Table of content: DR. MARTA J PETERSEN M.D. (NPI 1972601508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972601508 NPI number — DR. MARTA J PETERSEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
MARTA
Provider Middle Name:
J
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:
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:
1972601508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84110-3208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-587-6340
Provider Business Mailing Address Fax Number:
801-587-6346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 N MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84132-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-2955
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006

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: 207NS0135X , with the licence number:  1664261205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 1664261205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003054200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 870468377001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: J0854 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: XPY117280 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 070004834 . This is a "RR MEDICARE PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002089156 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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