Provider Demographics
NPI:1609803766
Name:CERMAK, PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:CERMAK
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:UFP PHALEN VILLAGE CLINIC
Mailing Address - Street 2:1414 MARYLAND AVENUE EAST
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106
Mailing Address - Country:US
Mailing Address - Phone:651-772-3461
Mailing Address - Fax:651-772-2605
Practice Address - Street 1:UFP PHALEN VILLAGE CLINIC
Practice Address - Street 2:1414 MARYLAND AVENUE EAST
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106
Practice Address - Country:US
Practice Address - Phone:651-772-3461
Practice Address - Fax:651-772-2605
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20653207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN04-02514OtherMEDICA CHOICE & PRIMARY
MN1000614OtherUCARE
WI31320300Medicaid
MN1027633OtherARAZ
MNHP15990OtherHEALTHPARTNERS
MN04-02443OtherMEDICA
MN440385100Medicaid
MN42G35CEOtherBCBS
IA1538967Medicare ID - Type UnspecifiedIA MA
MN110242989Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MNHP15990OtherHEALTHPARTNERS
MN440385100Medicaid