Basic Information
| Provider Information | |||||||||
| NPI: | 1578613618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ROSEMARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535963300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 209 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535963300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD00043414 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0214702 | 01 | WA | DEPARTMENT OF L&I | OTHER | 1280PE | 01 | WA | REGENCE | OTHER | 1780PE | 01 | WA | REGENCE | OTHER | 1802PE | 01 | WA | REGENCE | OTHER | 82456816 | 05 | WA | MEDICAID | 6410PE | 01 | WA | REGENCE | OTHER | P00249562 | 01 | WA | RAILROAD MEDICARE | OTHER | 1311 | 01 | WA | REGENCE | OTHER |