Provider Demographics
NPI:1902102502
Name:PETER ROGER DEVERSA MD PLLC
Entity Type:Organization
Organization Name:PETER ROGER DEVERSA MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:DEVERSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-802-0607
Mailing Address - Street 1:979 E 3RD ST
Mailing Address - Street 2:SUITE B-1001
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2136
Mailing Address - Country:US
Mailing Address - Phone:423-643-2576
Mailing Address - Fax:423-648-4570
Practice Address - Street 1:709 WALNUT ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-1916
Practice Address - Country:US
Practice Address - Phone:423-643-2576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty