1629056080 NPI number — DR. CAROL B PETERSON ED. D.

Table of content: DR. CAROL B PETERSON ED. D. (NPI 1629056080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629056080 NPI number — DR. CAROL B PETERSON ED. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
CAROL
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED. 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:
1629056080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7400 NEW LA GRANGE RD
Provider Second Line Business Mailing Address:
STE 312
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-4870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-394-9990
Provider Business Mailing Address Fax Number:
502-394-9992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7400 NEW LA GRANGE RD
Provider Second Line Business Practice Location Address:
STE 312
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40222-4870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-394-9990
Provider Business Practice Location Address Fax Number:
502-394-9992
Provider Enumeration Date:
01/05/2006

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: 103TC1900X , with the licence number:  1140 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130215 . This is a "APS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 243740 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7830266 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 89000129 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 177855 . This is a "COMPSYCH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2144611 . This is a "CIGNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 348656 . This is a "MHN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 273699000 . This is a "MAGELLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000174990 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 476947 . This is a "VALUE OPTIONS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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