Provider Demographics
NPI:1083806020
Name:STIG PEITERSEN MD PA
Entity Type:Organization
Organization Name:STIG PEITERSEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STIG
Authorized Official - Middle Name:E
Authorized Official - Last Name:PEITERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:936-699-4730
Mailing Address - Street 1:1111 W FRANK AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3323
Mailing Address - Country:US
Mailing Address - Phone:936-699-4730
Mailing Address - Fax:936-699-4737
Practice Address - Street 1:1111 W FRANK AVE STE 302
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3323
Practice Address - Country:US
Practice Address - Phone:936-699-4730
Practice Address - Fax:936-699-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141572101Medicaid
TX8429M0OtherBCBS
TX00190RMedicare PIN