Provider Demographics
NPI:1083895288
Name:PETER R FENWICK, MD
Entity Type:Organization
Organization Name:PETER R FENWICK, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:R
Authorized Official - Last Name:FENWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-786-7216
Mailing Address - Street 1:75 PRINGLE WAY STE 505
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1469
Mailing Address - Country:US
Mailing Address - Phone:775-786-7216
Mailing Address - Fax:775-786-9365
Practice Address - Street 1:75 PRINGLE WAY STE 505
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1469
Practice Address - Country:US
Practice Address - Phone:775-786-7216
Practice Address - Fax:775-786-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2016342Medicaid
NV2016342Medicaid
NVV33328Medicare PIN