Provider Demographics
NPI:1235171604
Name:AMBROSE B PETERMAN III DO FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:AMBROSE B PETERMAN III DO FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETERMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:610-327-1785
Mailing Address - Street 1:545 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-5677
Mailing Address - Country:US
Mailing Address - Phone:610-327-1785
Mailing Address - Fax:610-327-1414
Practice Address - Street 1:545 E HIGH ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-5677
Practice Address - Country:US
Practice Address - Phone:610-327-1785
Practice Address - Fax:610-327-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004830L207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75989Medicare UPIN