Provider Demographics
NPI:1083653778
Name:PETERSON, VIVIAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:MARIE
Other - Last Name:SCHAUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 NEUSE BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-3449
Mailing Address - Country:US
Mailing Address - Phone:252-633-8111
Mailing Address - Fax:
Practice Address - Street 1:2000 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3449
Practice Address - Country:US
Practice Address - Phone:252-633-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401561208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139K4OtherBCBS OF NC
NC5900914Medicaid
NC139K4OtherBCBS OF NC
NCG83234Medicare UPIN
NCP00264452Medicare PIN