Provider Demographics
NPI:1033502174
Name:PETERSON MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:PETERSON MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-258-7091
Mailing Address - Street 1:PO BOX 2421
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-1400
Mailing Address - Country:US
Mailing Address - Phone:830-258-6237
Mailing Address - Fax:830-315-1366
Practice Address - Street 1:575 HILL COUNTRY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6085
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:2015-03-13
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCNM2491367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty