1518918713 NPI number — MARCUS L PETERSON MD

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 1518918713 NPI number — MARCUS L PETERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MARCUS
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1518918713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
676 S BLUFF ST
Provider Second Line Business Mailing Address:
#207
Provider Business Mailing Address City Name:
ST GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84770-3568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-628-2895
Provider Business Mailing Address Fax Number:
435-628-5943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
676 S BLUFF ST
Provider Second Line Business Practice Location Address:
#207
Provider Business Practice Location Address City Name:
ST GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84770-3568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-628-2895
Provider Business Practice Location Address Fax Number:
435-628-5943
Provider Enumeration Date:
05/12/2006

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: 174400000X , with the licence number:  183446-1205 , 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: 201302847 . This is a "OTHER ID" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 19344612000001 . This is a "REGENCE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107029664101 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 201302841793981 . This is a "US HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2085401 . This is a "BCBS NV" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 902568 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 201302841 . This is a "CURRENT TAX ID" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870436699 . This is a "OLD TAX ID" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107007770102 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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