Provider Demographics
NPI:1962565085
Name:BLOMGREN, PETER FREDERICK (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:FREDERICK
Last Name:BLOMGREN
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 1:317 W WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-8401
Mailing Address - Country:US
Mailing Address - Phone:336-373-1794
Mailing Address - Fax:336-373-0505
Practice Address - Street 1:317 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-8401
Practice Address - Country:US
Practice Address - Phone:336-373-1794
Practice Address - Fax:336-373-0505
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC16316OtherBCBS
NC0102582OtherUNITED HEALTHCARE
NC080098543OtherMEDICARE RAILROAD
NC8916316-20Medicaid
NC080098543OtherMEDICARE RAILROAD
NC8916316-20Medicaid