Basic Information
| Provider Information | |||||||||
| NPI: | 1134309990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LITCHFIELD | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1019 W OAKLAND AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239155000 | ||||||||
| FaxNumber: | 4239155045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1019 W OAKLAND AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239155000 | ||||||||
| FaxNumber: | 4239155045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 30027 | AL | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 45503 | TN | Y | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 2013-00015 | NC | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | 065367 | GA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1516619 | 05 | TN | MEDICAID | 1134309990 | 05 | VA | MEDICAID |