1497715163 NPI number — DR. ROBERT G PETERSON M.D.

Table of content: DR. ROBERT G PETERSON M.D. (NPI 1497715163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497715163 NPI number — DR. ROBERT G PETERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
ROBERT
Provider Middle Name:
G
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:
1497715163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84127-0128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-442-1900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 NINTH AVE
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84103-2877
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-408-2233
Provider Business Practice Location Address Fax Number:
801-408-2870
Provider Enumeration Date:
03/25/2006

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: 207T00000X , with the licence number:  1800341205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 18541 . This is a "PUBLIC EMPLOYEES (PEHP)" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 870639983PE2 . This is a "EDUCATORS MUTUAL (EMIA)" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107004866104 . This is a "INTERMOUNTAIN HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 20110 . This is a "DESERET MUTUAL (DMBA)" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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