Basic Information
| Provider Information | |||||||||
| NPI: | 1942216445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678207 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752678207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008414236 | ||||||||
| FaxNumber: | 7066531162 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E WOOD ST | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293033040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645606522 | ||||||||
| FaxNumber: | 8889728644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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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 | 2085R0202X | 4301064032 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 52290 | SC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 310E011330 | 01 | MI | BCBS OF MI GROUP PIN | OTHER | 1942216445 | 05 | MI | MEDICAID | CI8050 | 01 | MI | MEDICARE RR GROUP PIN/PALMETTO GBA | OTHER |