Provider Demographics
NPI:1316298326
Name:JEFFREY R PETERMAN MD PC
Entity type:Organization
Organization Name:JEFFREY R PETERMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-253-9374
Mailing Address - Street 1:333 MAGAZINE STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783
Mailing Address - Country:US
Mailing Address - Phone:906-253-9374
Mailing Address - Fax:906-253-9002
Practice Address - Street 1:333 MAGAZINE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1867
Practice Address - Country:US
Practice Address - Phone:906-253-9374
Practice Address - Fax:906-253-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073421385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4369143Medicaid
MI4369143Medicaid
MION40570Medicare PIN