Basic Information
| Provider Information | |||||||||
| NPI: | 1063477974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 ALBANY ST FL G | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021193791 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 830 HARRISON AVENUE | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176388124 | ||||||||
| FaxNumber: | 6176386424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 35079500W | OH | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 278034 | NY | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 253255 | MA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 2249534 | 05 | OH | MEDICAID |