Basic Information
| Provider Information | |||||||||
| NPI: | 1336126721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | AARON | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 202 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774062916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4101 WAGON TRAIL AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891184426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029424123 | ||||||||
| FaxNumber: | 7029424124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 01/11/2013 | ||||||||
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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 | 2471C3402X | A82742 | CA | N | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography | 2085R0202X | 036116322 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 12283 | NV | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00440881 | 01 | RR MEDICARE | OTHER | 1336126721 | 05 | NV | MEDICAID |