1316916554 NPI number — ROGER L PETERSON PHD

Table of content: ROGER L PETERSON PHD (NPI 1316916554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316916554 NPI number — ROGER L PETERSON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
ROGER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1316916554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 PHOENIX MILL LN
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
PETERBOROUGH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03458-1476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-924-7797
Provider Business Mailing Address Fax Number:
603-822-2813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 WEST ST STE 29B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEENE
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03431-2458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-903-3373
Provider Business Practice Location Address Fax Number:
603-357-1185
Provider Enumeration Date:
03/17/2006

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: 103T00000X , with the licence number:  LP286 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30006111 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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