Provider Demographics
NPI:1629003819
Name:PETERSON LABORATORY SERVICES, PA
Entity Type:Organization
Organization Name:PETERSON LABORATORY SERVICES, PA
Other - Org Name:PETERSON CLINICAL LABORATORY, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-539-5363
Mailing Address - Street 1:1133 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2770
Mailing Address - Country:US
Mailing Address - Phone:785-539-5363
Mailing Address - Fax:785-539-5862
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-539-5363
Practice Address - Fax:785-539-5862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17D0449919207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSCE1332OtherRR MEDICARE
KS003989Medicare PIN