Provider Demographics
NPI:1053500413
Name:CAROL E. PETERSON, MD PLC
Entity Type:Organization
Organization Name:CAROL E. PETERSON, MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT ACCOUNTS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:BOEREMA
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:231-757-1260
Mailing Address - Street 1:6050 N US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:FREE SOIL
Mailing Address - State:MI
Mailing Address - Zip Code:49411-9157
Mailing Address - Country:US
Mailing Address - Phone:231-757-1260
Mailing Address - Fax:231-757-1261
Practice Address - Street 1:6050 N US HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:FREE SOIL
Practice Address - State:MI
Practice Address - Zip Code:49411-9157
Practice Address - Country:US
Practice Address - Phone:231-757-1260
Practice Address - Fax:231-757-1261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050870207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0531035OtherBLUE CROSS BLUS SHIELD
MI4831985Medicaid
MIC39622Medicare UPIN
MI0P26170Medicare PIN
MI0531035OtherBLUE CROSS BLUS SHIELD