Basic Information
| Provider Information | |||||||||
| NPI: | 1437223237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11225 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374012225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238925602 | ||||||||
| FaxNumber: | 4238925838 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 E THIRD ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237787608 | ||||||||
| FaxNumber: | 4237782360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 01/14/2010 | ||||||||
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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 | 207L00000X | MD17828 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 009102570 | 05 | AL | MEDICAID | 3039778 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | 050013519 | 01 | TN | MEDICARE RAILROAD | OTHER | 890692J | 05 | NC | MEDICAID | 3028382 | 05 | TN | MEDICAID | N348391 | 01 | GA | WELLCARE (GA MEDICAID) | OTHER | 000370829C | 05 | GA | MEDICAID |