1477555225 NPI number — ALAN C PETERSON M.D.

Table of content: ALAN C PETERSON M.D. (NPI 1477555225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477555225 NPI number — ALAN C PETERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
ALAN
Provider Middle Name:
C
Provider Name Prefix Text:
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:
1477555225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6920 POINTE INVERNESS WAY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-7934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-479-3514
Provider Business Mailing Address Fax Number:
260-479-3520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7910 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-2297
Provider Business Practice Location Address Fax Number:
260-434-6420
Provider Enumeration Date:
08/11/2005

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: 208G00000X , with the licence number:  01031812A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 330005240 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 2907251 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0518649 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100096130 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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