1164406955 NPI number — DR. MARY ELIZABETH PETERSON AU.D.

Table of content: DR. MARY ELIZABETH PETERSON AU.D. (NPI 1164406955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164406955 NPI number — DR. MARY ELIZABETH PETERSON AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON-COMBS
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164406955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 OAKLAND DR FL 3
Provider Second Line Business Mailing Address:
WMU UNIFIED CLINICS CHARLES VAN RIPER LANGUAGE SPEECH
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49008-1282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-387-7209
Provider Business Mailing Address Fax Number:
269-387-7227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 OAKLAND DR FL 3
Provider Second Line Business Practice Location Address:
WMU UNIFIED CLINICS CHARLES VAN RIPER LANGUAGE SPEECH
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49008-1282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-387-7209
Provider Business Practice Location Address Fax Number:
269-387-7227
Provider Enumeration Date:
12/05/2005

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: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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