Basic Information
| Provider Information | |||||||||
| NPI: | 1245203892 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 SIXTH STREET | ||||||||
| Address2: | NYMH DEPT OF MEDICINE | ||||||||
| City: | BROOKLN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112159008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187805246 | ||||||||
| FaxNumber: | 7187803259 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 SIXTH STREET | ||||||||
| Address2: | NYMH DEPARTMENT OF MEDICINE | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112159008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187805246 | ||||||||
| FaxNumber: | 7187803259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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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 | 207R00000X | 165002 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4622237 | 01 | NY | AETNA PPO | OTHER | 01009365 | 05 | NY | MEDICAID | 1201593 | 01 | NY | UNITED HEALTHCARE | OTHER | 68D251 | 01 | NY | BCBS OF NY WHITE PLAINS | OTHER | 110123567 | 01 | NY | RAILROAD MEDICARE | OTHER | 0492111 | 01 | NY | AETNA HMO | OTHER | WP722 | 01 | NY | OXFORD | OTHER |