Provider Demographics
NPI:1508845421
Name:PETERSON, CALVIN H (PAC)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:H
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:508-909-7799
Mailing Address - Fax:508-764-2432
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-9771
Practice Address - Fax:508-764-2448
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC500000139363A00000X
MAPA1146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000867643Medicaid
DE000867643Medicaid
S57180Medicare UPIN