Provider Demographics
NPI:1609820877
Name:FOSTER-FISHMAN, PETER RUSSELL (PSYD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:RUSSELL
Last Name:FOSTER-FISHMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 CRESENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-4120
Mailing Address - Country:US
Mailing Address - Phone:517-337-2715
Mailing Address - Fax:517-337-2715
Practice Address - Street 1:1046 CRESENWOOD RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-4120
Practice Address - Country:US
Practice Address - Phone:517-337-2715
Practice Address - Fax:517-337-2715
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009240103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS37256Medicare UPIN
MIOM26860Medicare ID - Type Unspecified