Provider Demographics
NPI:1609166545
Name:RYAN C PETERSON MD INC
Entity Type:Organization
Organization Name:RYAN C PETERSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-266-3774
Mailing Address - Street 1:PO BOX 7001
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
Practice Address - Street 1:3209 HILLOCK DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1427
Practice Address - Country:US
Practice Address - Phone:310-266-3774
Practice Address - Fax:323-380-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103097207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEO751BMedicare PIN