Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207L00000X | Anesthesiologist | 5101014120 | MI |
N | 207P00000X | Emergency Physician | 5101014120 | MI |
Y | 207PE0004X | Emergency Medical Services | 5101014120 | MI |
NPI | 1205819059 |
---|---|
Provider Name | Ryan A Peters |
First Address | Chicago, IL 60689-5325 |
Second Address | Grand Rapids, MI 49503-2560 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/11/2005 |
Last Update Date | 27/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H85263 | (02) | MI |
P00077095 | RAILROAD MEDICARE (01) | |
RP014120 | BLUE CROSS BLUE SHIELD (01) |