1255475166 NPI number — SUSAN PETERSON

Table of content: SUSAN PETERSON (NPI 1255475166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255475166 NPI number — SUSAN PETERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1255475166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 OLD HARMONY RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-4184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-224-6020
Provider Business Mailing Address Fax Number:
302-224-6017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 OLD HARMONY RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-4184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-224-6020
Provider Business Practice Location Address Fax Number:
302-224-6017
Provider Enumeration Date:
02/16/2007

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: 103TM1800X , with the licence number:  B1-000303 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103K00000X , with the licence number: 1-01-0655 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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