Basic Information
Provider Information | |||||||||
NPI: | 1730126954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIAMOND | ||||||||
FirstName: | PETER | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | W3985 COUNTY ROAD NN | ||||||||
Address2: |   | ||||||||
City: | ELKHORN | ||||||||
State: | WI | ||||||||
PostalCode: | 531214337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2627412000 | ||||||||
FaxNumber: | 2627412180 | ||||||||
Practice Location | |||||||||
Address1: | W3985 COUNTY ROAD NN | ||||||||
Address2: |   | ||||||||
City: | ELKHORN | ||||||||
State: | WI | ||||||||
PostalCode: | 531214337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2627412000 | ||||||||
FaxNumber: | 2627412180 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2006 | ||||||||
LastUpdateDate: | 11/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 67017 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 1616378 | 01 | ID | BCBS | OTHER | L57038 | 01 | IL | MEDICARE PIN-LOCALITY 16 | OTHER | 1316998578 | 01 | IL | NPI GROUP PRACTICE | OTHER | L71656 | 01 | IL | MEDICARE PIN-LOCALITY 15 | OTHER | 060041167 | 01 | IL | RRMC-LOCALITY 16 | OTHER | 4064709 | 01 | IL | AETNA | OTHER |