1265549869 NPI number — DR. MCKIM C PETERSON M. D.

Table of content: DR. MCKIM C PETERSON M. D. (NPI 1265549869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265549869 NPI number — DR. MCKIM C PETERSON M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
MCKIM
Provider Middle Name:
C
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:
1265549869
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1079
Provider Second Line Business Mailing Address:
MIDCOAST MEDICINE, PA
Provider Business Mailing Address City Name:
ROCKPORT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04856-1079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-236-2169
Provider Business Mailing Address Fax Number:
207-230-0413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 UNION ST
Provider Second Line Business Practice Location Address:
MIDCOAST MEDICINE, PA
Provider Business Practice Location Address City Name:
ROCKPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04856-6107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-236-2169
Provider Business Practice Location Address Fax Number:
207-230-0413
Provider Enumeration Date:
08/23/2006

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: 207Q00000X , with the licence number:  013075 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130430000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com