Basic Information
| Provider Information | |||||||||
| NPI: | 1619918752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RIVER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003550808 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 W SILVER ST | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010853628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135682811 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 11/26/2007 | ||||||||
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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 | 207P00000X | 51297 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3054667 | 05 | MA | MEDICAID | 15373 | 01 | MA | HEALTHCARE NEW ENGLAND | OTHER | 110198433 | 01 | MA | RAILROAD MEDICARE | OTHER | 000000033017 | 01 | MA | BMC HEALTH NET | OTHER | PEJ07622 | 01 | MA | BLUE SHIELD | OTHER |