Basic Information
| Provider Information | |||||||||
| NPI: | 1659374262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5655 HUDSON DR STE 210 | ||||||||
| Address2: | ARIS RADIOLOGY | ||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442364455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306551869 | ||||||||
| FaxNumber: | 3306553828 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 OAKSIDE LN | ||||||||
| Address2: | STE A | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301146416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704791945 | ||||||||
| FaxNumber: | 7704791948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 051890 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 202673 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 26644 | AL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000964268L | 05 | GA | MEDICAID |