Provider Demographics
NPI:1659313880
Name:PETER ANDERSON MD MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PETER ANDERSON MD MEDICAL CORPORATION
Other - Org Name:EMERGENCY PHYSICIANS FOUNTAIN VALLEY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-809-3572
Mailing Address - Street 1:PO BOX 51726
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-6026
Mailing Address - Country:US
Mailing Address - Phone:562-809-3572
Mailing Address - Fax:
Practice Address - Street 1:17100 EUCLID ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4004
Practice Address - Country:US
Practice Address - Phone:714-966-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0046600Medicaid
CAHW11279Medicare PIN