1245203892 NPI number — DR. STEPHEN J PETERSON M.D.

Table of content: DR. STEPHEN J PETERSON M.D. (NPI 1245203892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245203892 NPI number — DR. STEPHEN J PETERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
STEPHEN
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1245203892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 SIXTH STREET
Provider Second Line Business Mailing Address:
NYMH DEPT OF MEDICINE
Provider Business Mailing Address City Name:
BROOKLN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11215-9008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-780-5246
Provider Business Mailing Address Fax Number:
718-780-3259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 SIXTH STREET
Provider Second Line Business Practice Location Address:
NYMH DEPARTMENT OF MEDICINE
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11215-9008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-780-5246
Provider Business Practice Location Address Fax Number:
718-780-3259
Provider Enumeration Date:
02/13/2006

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: 207R00000X , with the licence number:  165002 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0492111 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4622237 . This is a "AETNA PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: WP722 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01009365 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1201593 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 110123567 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 68D251 . This is a "BCBS OF NY WHITE PLAINS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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