Basic Information
| Provider Information | |||||||||
| NPI: | 1659344414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACKERMAN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | Y | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3927 RUCKER AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 07/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00036311 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 050071892 | 01 | WA | RAILROAD MEDICARE | OTHER | 0039515 | 01 | WA | L & I | OTHER | 8243669 | 05 | WA | MEDICAID | AC5531 | 01 | WA | INDIVIDUAL BLUE SHIELD | OTHER |