Provider Demographics
NPI:1063451706
Name:PETERS, BRYAN MACLIN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:MACLIN
Last Name:PETERS
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:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-789-4461
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6504
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-789-4461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC288882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC63163OtherMEDCOST
NC8967158Medicaid
NC16-54647OtherUNITED HEALTHCARE
NC16-54648OtherUNITED HEALTHCARE
NC63129OtherMEDCOST
NC63191OtherMEDCOST
NC16-54646OtherUNITED HEALTHCARE
NC67158OtherBLUECROSS BLUESHIELD
NC16-54648OtherUNITED HEALTHCARE
NC212607Medicare ID - Type Unspecified
NC16-54647OtherUNITED HEALTHCARE
NC8967158Medicaid