Provider Demographics
NPI:1164522629
Name:THOMAS R PETERSON MD PC
Entity Type:Organization
Organization Name:THOMAS R PETERSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-525-0500
Mailing Address - Street 1:140 PROSPECT AVE
Mailing Address - Street 2:SUITE 18
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07600
Mailing Address - Country:US
Mailing Address - Phone:201-525-0500
Mailing Address - Fax:201-525-1171
Practice Address - Street 1:140 PROSPECT AVE
Practice Address - Street 2:SUITE 18
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07600
Practice Address - Country:US
Practice Address - Phone:201-525-0500
Practice Address - Fax:201-525-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA5194207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0154105Medicaid
NJ0154105Medicaid
E28793Medicare UPIN