1972552107 NPI number — JEFFREY JUSTIN PETERSON MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972552107 NPI number — JEFFREY JUSTIN PETERSON MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PETERSON

Provider First Name:

JEFFREY

Provider Middle Name:

JUSTIN

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1972552107

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/06/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

5605 GLENRIDGE DR STE 325

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ATLANTA

Provider Business Mailing Address State Name:

GA

Provider Business Mailing Address Postal Code:

30342-1365

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

678-553-7783

Provider Business Mailing Address Fax Number:

678-553-7793

Provider First Line Business Practice Location Address:

1000 JOHNSON FERRY RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ATLANTA

Provider Business Practice Location Address State Name:

GA

Provider Business Practice Location Address Postal Code:

30342

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

404-851-6323

Provider Business Practice Location Address Fax Number:

404-303-3747

Provider Enumeration Date:

05/06/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085R0202X , with the licence number:  47555 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0202X , with the licence number: 066883 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: P00252409 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 16-03566 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: P00285261 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
• Identifier: 171P6PE . This is a "BLUE CROSS/BLUE SHIELD OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 0592113 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1935877 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 390400800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 34649100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
• Identifier: 9249279 . This is a "DAKOTA CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: HP52064 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 135108 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".