Provider Demographics
NPI:1407838048
Name:BISTOLARIDES, PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:BISTOLARIDES
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 1:4201 CAMPUS RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640
Mailing Address - Country:US
Mailing Address - Phone:989-839-1795
Mailing Address - Fax:989-839-1785
Practice Address - Street 1:4201 CAMPUS RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-839-1795
Practice Address - Fax:989-839-1785
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064856208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020G361410OtherBCBSM GROUP PIN
156543OtherGREAT LAKES HEALTH PLAN
P00348487OtherRAILROAD MEDICARE
MI104905069Medicaid
0993608OtherHEALTHPLUS OF MICHIGAN
MIPB064856OtherSTATE LICENSE
P00348487OtherRAILROAD MEDICARE
0993608OtherHEALTHPLUS OF MICHIGAN