1174668081 NPI number — TIMOTH Y JOHN PETERSON

Table of content: TIMOTH Y JOHN PETERSON (NPI 1174668081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174668081 NPI number — TIMOTH Y JOHN PETERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
TIMOTH Y
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1174668081
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:
213 E CECIL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUS FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56537-1416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-736-3507
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ST. FRANCIS HEALTHCARE CAMPUS
Provider Second Line Business Practice Location Address:
2400 ST. FRANCIS DRIVE
Provider Business Practice Location Address City Name:
BRECKENRIDGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-643-0345
Provider Business Practice Location Address Fax Number:
218-643-0853
Provider Enumeration Date:
02/20/2007

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: 282NC0060X , with the licence number:  102006 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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