Basic Information
| Provider Information | |||||||||
| NPI: | 1144436569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | DARREL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4020 WESTCHASE BLVD | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276073938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198342767 | ||||||||
| FaxNumber: | 9198340234 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843023 | ||||||||
| FaxNumber: | 9197843497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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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 | 2006-00627 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 5911234 | 05 | NC | MEDICAID |