1164482212 NPI number — MR. WILLIAM HARRELD PETERSON PA-C

Table of content: LINDA STORY STEPHENSON LICSW (NPI 1174664346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164482212 NPI number — MR. WILLIAM HARRELD PETERSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
WILLIAM
Provider Middle Name:
HARRELD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1164482212
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1313 PINE GROVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND LAKE BEACH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60073-2152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-688-6755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3420 ILLINOIS ST
Provider Second Line Business Practice Location Address:
USS TRANQUILITY MEDICAL CLINIC 1007
Provider Business Practice Location Address City Name:
GREAT LAKES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60088-5230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-688-6755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2006

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: 363A00000X , with the licence number:  2000-PA22 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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