Provider Demographics
NPI:1598790099
Name:WITHERELL, PETER M (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:WITHERELL
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:PO BOX 3012
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:302-224-5678
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:3411 SILVERSIDE ROAD
Practice Address - Street 2:SUITE 103 RODNEY BUILDING
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810
Practice Address - Country:US
Practice Address - Phone:302-478-7001
Practice Address - Fax:302-478-7002
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0004878207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000752101Medicaid
G06575Medicare UPIN
DE00B719I38Medicare ID - Type Unspecified