Provider Demographics
NPI:1316926397
Name:SODERBERG, PEER A (MD)
Entity type:Individual
Prefix:
First Name:PEER
Middle Name:A
Last Name:SODERBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:5566 JORDAN RD
Practice Address - Street 2:
Practice Address - City:ELBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13060-9617
Practice Address - Country:US
Practice Address - Phone:315-689-1833
Practice Address - Fax:315-689-1834
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC1863Medicare PIN
NYH24865Medicare UPIN
NY080162114Medicare PIN