1669490140 NPI number — MR. LAUREN L PETERSON JR. CRNA

Table of content: MR. LAUREN L PETERSON JR. CRNA (NPI 1669490140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669490140 NPI number — MR. LAUREN L PETERSON JR. CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
LAUREN
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
CRNA
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:
1669490140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7764 FOREST CREEK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUMEE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43537-9140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-868-8329
Provider Business Mailing Address Fax Number:
419-868-8329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7764 FOREST CREEK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAUMEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43537-9140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-690-7652
Provider Business Practice Location Address Fax Number:
419-697-7726
Provider Enumeration Date:
07/17/2006

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: 367500000X , with the licence number:  NA04744 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: RN255183 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04097A . This is a "PHC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000519766 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341881145-003 . This is a "MMO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000389988 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00439234 . This is a "RRMC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5182102 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2150569 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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