Basic Information
| Provider Information | |||||||||
| NPI: | 1043206881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LITTRUP | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 CATAMORE BLVD | ||||||||
| Address2: | |||||||||
| City: | EAST PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322500 | ||||||||
| FaxNumber: | 2488277663 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 JOHN R RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137458042 | ||||||||
| FaxNumber: | 3137452314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301050249 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 14797 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 700H261920 | 01 | MI | BCBS | OTHER |