1629152301 NPI number — DR. LAURIS J PETERSEN MD

Table of content: DR. LAURIS J PETERSEN MD (NPI 1629152301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629152301 NPI number — DR. LAURIS J PETERSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
LAURIS
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629152301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 MONARDA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTIA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12302-4202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 GLENRIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12302-4520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-399-0909
Provider Business Practice Location Address Fax Number:
518-399-2640
Provider Enumeration Date:
10/25/2006

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: 207Q00000X , with the licence number:  213320 , 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: 000491234003 . This is a "BLUE SHIELD OF NENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 76V271 . This is a "EMPIRE BLUE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10031080 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 714547 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P00315575 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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