Basic Information
| Provider Information | |||||||||
| NPI: | 1568457257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETEREIT | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | GRANT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8010 | ||||||||
| Address2: | 353 FAIRMONT BLVD | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577098010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057198559 | ||||||||
| FaxNumber: | 6057192310 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057198559 | ||||||||
| FaxNumber: | 6057192310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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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 | 2085R0001X | 4542 | SD | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 31368 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 920005340 | 01 | RAILROAD MEDICARE | OTHER | 6630570 | 05 | SD | MEDICAID | 120275800 | 05 | WY | MEDICAID |