Provider Demographics
NPI:1770800575
Name:PETERSON MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:PETERSON MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-258-7632
Mailing Address - Street 1:PO BOX 26499
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2015
Mailing Address - Country:US
Mailing Address - Phone:830-258-7343
Mailing Address - Fax:830-258-7678
Practice Address - Street 1:575 HILL COUNTRY DR
Practice Address - Street 2:STE 202
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6024
Practice Address - Country:US
Practice Address - Phone:830-258-6237
Practice Address - Fax:830-315-1366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX550119207Q00000X, 207R00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB108390Medicare PIN