Provider Demographics
NPI:1346312592
Name:VANDER WEIDE, PETER (PT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:VANDER WEIDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 CAPITAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-9354
Mailing Address - Country:US
Mailing Address - Phone:269-979-3000
Mailing Address - Fax:269-979-9770
Practice Address - Street 1:3480 CAPITAL AVE SW
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-9354
Practice Address - Country:US
Practice Address - Phone:269-979-3000
Practice Address - Fax:269-979-9770
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004402225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist