Provider Demographics
NPI:1659376010
Name:CRECELIUS, PETER W (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:W
Last Name:CRECELIUS
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 1:301 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-9029
Mailing Address - Country:US
Mailing Address - Phone:208-476-4555
Mailing Address - Fax:208-476-5385
Practice Address - Street 1:301 CEDAR ST
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9029
Practice Address - Country:US
Practice Address - Phone:208-476-4555
Practice Address - Fax:208-476-5385
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDB63862OtherUPIN #
ID000175600Medicaid
ID1118976Medicare PIN