Provider Demographics
NPI:1699871087
Name:BLUE, PETER WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:WILLIAM
Last Name:BLUE
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 1:4500 STUART STREET
Mailing Address - Street 2:MONCRIEF ARMY HOSPITAL; ATTN: MCXL-PQ (CREDENTIALS)
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5720
Mailing Address - Country:US
Mailing Address - Phone:803-751-2618
Mailing Address - Fax:803-751-2689
Practice Address - Street 1:4500 STUART STREET
Practice Address - Street 2:MONCRIEF ARMY HOSPITAL; ATTN: MCXL-PQ (CREDENTIALS)
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5720
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:803-751-2689
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27241207RE0101X, 207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Not Answered207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN