Provider Demographics
NPI:1063876019
Name:PETERSON, ANDREA MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3254
Mailing Address - Country:US
Mailing Address - Phone:843-405-9918
Mailing Address - Fax:
Practice Address - Street 1:1375 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3254
Practice Address - Country:US
Practice Address - Phone:843-405-9918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA93452207VE0102X, 207VG0400X
SC87872207VG0400X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology