Basic Information
| Provider Information | |||||||||
| NPI: | 1306844105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKERNAN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | SELECT PHYSICIANS ALLIANCE | ||||||||
| Address2: | 10002 PRINCESS PALM AVE. STE 332 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336198327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135717184 | ||||||||
| FaxNumber: | 8136544695 | ||||||||
| Practice Location | |||||||||
| Address1: | EAR NOST & THROAT ASSOCIATES | ||||||||
| Address2: | 6101 WEBB RD. STE 211 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336152865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138844967 | ||||||||
| FaxNumber: | 8138890847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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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 | 207Y00000X | M.E. 0056480 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0621641 | 05 | FL | MEDICAID |