Provider Demographics
NPI:1063611267
Name:PETER ANDERSON
Entity type:Organization
Organization Name:PETER ANDERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PCP
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-355-3728
Mailing Address - Street 1:1 OLD PARK LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2562
Mailing Address - Country:US
Mailing Address - Phone:860-355-3728
Mailing Address - Fax:860-355-4253
Practice Address - Street 1:1 OLD PARK LN
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2562
Practice Address - Country:US
Practice Address - Phone:860-355-3728
Practice Address - Fax:860-355-4253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000613363LF0000X
CT025352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001253525Medicaid
CTC01692Medicare PIN
CTB38456Medicare UPIN