Provider Demographics
NPI:1003137613
Name:PETERSON, PHILLIP ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9350
Mailing Address - Country:US
Mailing Address - Phone:570-522-4110
Mailing Address - Fax:570-768-3911
Practice Address - Street 1:ONE HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9350
Practice Address - Country:US
Practice Address - Phone:570-522-2640
Practice Address - Fax:570-768-3921
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD447379207P00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028234030003Medicaid