Provider Demographics
NPI:1245416536
Name:PETER, MARY T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:PETER
Suffix:
Gender:F
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:SPRINGFIELD RADIOLOGISTS ST JOHNS HOSPITAL
Mailing Address - Street 2:800 E. CARPENTER STREET
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:
Practice Address - Street 1:SPRINGFIELD RADIOLOGISTS ST JOHNS HOSPITAL
Practice Address - Street 2:800 E. CARPENTER STREET
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1182572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118257Medicaid
ILE19177Medicare UPIN