1770800575 NPI number — PETERSON MEDICAL ASSOCIATES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770800575 NPI number — PETERSON MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETERSON MEDICAL ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1770800575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26499
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-2015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-258-7343
Provider Business Mailing Address Fax Number:
830-258-7678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 HILL COUNTRY DR
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-6024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-258-6237
Provider Business Practice Location Address Fax Number:
830-315-1366
Provider Enumeration Date:
05/03/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEDOVICH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
830-258-7632

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  550119 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 550119 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 550119 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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