Provider Demographics
NPI:1033126974
Name:PETERSON, SCOTT MICHAEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:LEMOYNE COLLEGE SPORTS MEDICINE
Mailing Address - Street 2:1419 SALT SPRINGS ROAD
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1399
Mailing Address - Country:US
Mailing Address - Phone:315-445-4417
Mailing Address - Fax:315-445-6048
Practice Address - Street 1:LEMOYNE COLLEGE SPORTS MEDICINE
Practice Address - Street 2:1419 SALT SPRINGS ROAD
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1399
Practice Address - Country:US
Practice Address - Phone:315-445-4417
Practice Address - Fax:315-445-6048
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY000727-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer