Basic Information
| Provider Information | |||||||||
| NPI: | 1891766812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | HUBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1258 | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679051258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206268500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1436 N WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679012212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206268500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 04-22995 | KS | X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0105X | 04-22995 | KS | X | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
No ID Information.