Provider Demographics
NPI:1891894648
Name:PETERSON, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 NORTHGATE PK
Mailing Address - Street 2:STE 201
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415
Mailing Address - Country:US
Mailing Address - Phone:423-870-5647
Mailing Address - Fax:423-870-5545
Practice Address - Street 1:1 NORTHGATE PARK
Practice Address - Street 2:NEW BEGINNINGS COUNSELING CENTER STE 201
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415
Practice Address - Country:US
Practice Address - Phone:423-870-5647
Practice Address - Fax:423-870-5545
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN109782084P0800X
GA320192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
3025475Medicare ID - Type Unspecified
A98955Medicare UPIN