Basic Information
| Provider Information | |||||||||
| NPI: | 1306911995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANNAPOLIS ASTHMA PULMONARY AND SLEEP SPEC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | SUITE 607 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102661644 | ||||||||
| FaxNumber: | 4102661642 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | SUITE 607 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102661644 | ||||||||
| FaxNumber: | 4102661642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 06/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4102661644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | P00317246 | 01 | MD | MEDICARE RAILROAD | OTHER |