Provider Demographics
NPI:1154324093
Name:PETERSON, ERIC W (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
Last Name:PETERSON
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 1:1436 RIVERCHASE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1777
Mailing Address - Country:US
Mailing Address - Phone:803-329-2636
Mailing Address - Fax:803-329-2184
Practice Address - Street 1:1436 RIVERCHASE BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1777
Practice Address - Country:US
Practice Address - Phone:803-329-2636
Practice Address - Fax:803-329-2184
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17811207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT18326Medicaid
SCF197433754Medicare PIN
SCF19743Medicare UPIN