Provider Demographics
NPI:1164644142
Name:PETER DEXHEIMER PA
Entity Type:Organization
Organization Name:PETER DEXHEIMER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DEXHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-531-6550
Mailing Address - Street 1:10840 LITTLE PATUXENT PKWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3115
Mailing Address - Country:US
Mailing Address - Phone:410-531-6550
Mailing Address - Fax:410-531-6552
Practice Address - Street 1:10840 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE 203
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3115
Practice Address - Country:US
Practice Address - Phone:410-531-6550
Practice Address - Fax:410-531-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01181305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT93049Medicare UPIN
MD996QMedicare ID - Type Unspecified