Provider Demographics
NPI:1336107002
Name:PETERMAN, J MARK (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:MARK
Last Name:PETERMAN
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 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FL
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1000
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:2ND FL
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1619
Practice Address - Country:US
Practice Address - Phone:413-794-7246
Practice Address - Fax:413-794-7137
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44386207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
B74032Medicare UPIN
G01049Medicare ID - Type Unspecified