Provider Demographics
NPI:1437130606
Name:VANDEMARK, PETER S (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
Last Name:VANDEMARK
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 1:1019 CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307
Mailing Address - Country:US
Mailing Address - Phone:231-591-5961
Mailing Address - Fax:231-591-5970
Practice Address - Street 1:1019 CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307
Practice Address - Country:US
Practice Address - Phone:231-591-5961
Practice Address - Fax:231-591-5970
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0540004OtherBLUE CROSS BLUE SHIELD
MI110154022OtherPALMETTO GBA RAILROAD MR
MI3377875Medicaid
MI3377875Medicaid
MI0540004OtherBLUE CROSS BLUE SHIELD