Basic Information
| Provider Information | |||||||||
| NPI: | 1699713495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 555 N DUKE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176022250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175445511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 317 S CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | QUARRYVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175661344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177867383 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 04/12/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD014323E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0006850290003 | 01 | PA | RR MEDICARE | OTHER | 0006850290003 | 05 | PA | MEDICAID | 30027962 | 01 | PA | KEYSTONE MERCY | OTHER | 000000127269 | 01 | PA | UNISON | OTHER | 000000127269 | 01 | PA | GATEWAY | OTHER | 0038488000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 0555758 | 01 | PA | AETNA-HMO | OTHER | 100364D | 01 | PA | MERCY | OTHER | 5898345 | 01 | PA | AETNA-NON HMO | OTHER | 7376572 | 01 | PA | CIGNA | OTHER | 50055854 | 01 | PA | CAPITAL BLUE CROSS/KEYSTONE HEALTH PLAN CENTRAL | OTHER | 000142601 | 01 | PA | HIGHMARK | OTHER | 35903 | 01 | PA | GEISINGER | OTHER |