Basic Information
| Provider Information | |||||||||
| NPI: | 1518587351 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2206 N 179TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681162264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703765425 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7500 MERCY RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023986060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2020 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R-11882 | IA | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | TEP9013 | NE | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.