Basic Information
Provider Information | |||||||||
NPI: | 1528046968 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETERS | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 275 SANDWICH ST | ||||||||
Address2: | C/O CATHY GREY | ||||||||
City: | PLYMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 023602183 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087462000 | ||||||||
FaxNumber: | 5088302502 | ||||||||
Practice Location | |||||||||
Address1: | 528 WASHINGTON HWY | ||||||||
Address2: |   | ||||||||
City: | MORRISVILLE | ||||||||
State: | VT | ||||||||
PostalCode: | 056618973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028888173 | ||||||||
FaxNumber: | 8028888365 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2006 | ||||||||
LastUpdateDate: | 07/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 204818 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 0420011854 | VT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1016965 | 05 | VT |   | MEDICAID | 69997 | 01 | MA | HARVARD PILGRIM | OTHER | 0100862 | 05 | MA |   | MEDICAID | 409393 | 01 | MA | TUFTS HEALTH PLAN | OTHER | J22421 | 01 | MA | BCBSMA | OTHER |