Basic Information
Provider Information | |||||||||
NPI: | 1215903372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEARDEN | ||||||||
FirstName: | PETER | ||||||||
MiddleName: | DREW | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD,PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 191 | ||||||||
Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
City: | ROCKLAND | ||||||||
State: | DE | ||||||||
PostalCode: | 197320191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026516212 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13535 NEMOURS PKWY | ||||||||
Address2: | NEMOURS CHILDRENS HOSPITAL | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328277402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075674000 | ||||||||
FaxNumber: | 4075675924 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2006 | ||||||||
LastUpdateDate: | 03/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD422307 | PA | N |   | Other Service Providers | Specialist |   | 208G00000X | ME118912 | FL | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 012929500 | 05 | FL |   | MEDICAID | 001965321 | 05 | PA |   | MEDICAID |