Provider Demographics
NPI:1689132045
Name:EIDSMOE, PETER (PT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:EIDSMOE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 S GREEN BAY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4468
Mailing Address - Country:US
Mailing Address - Phone:262-321-0240
Mailing Address - Fax:262-321-0242
Practice Address - Street 1:2915 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2626
Practice Address - Country:US
Practice Address - Phone:414-282-7810
Practice Address - Fax:414-282-9120
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14535225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist