Basic Information
| Provider Information | |||||||||
| NPI: | 1568618916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | TIM | ||||||||
| MiddleName: | GERARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 TULANE AVE # TW22 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049882300 | ||||||||
| FaxNumber: | 5049887389 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 TULANE AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049882300 | ||||||||
| FaxNumber: | 5049887389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2008 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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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 | 207ZB0001X | 020904 | LA | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZP0102X | 020904 | LA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.