Basic Information
| Provider Information | |||||||||
| NPI: | 1952783698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652121000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738842912 | ||||||||
| FaxNumber: | 5738847060 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 N HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652512511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736425911 | ||||||||
| FaxNumber: | 5736423015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2015 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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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 | 207Q00000X | 2015019323 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.