Provider Demographics
NPI:1942375050
Name:HANDLEY, PETER R (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:HANDLEY
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 1:1722 GOLDEN RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8955
Mailing Address - Country:US
Mailing Address - Phone:989-731-2140
Mailing Address - Fax:989-731-2205
Practice Address - Street 1:825 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1592
Practice Address - Country:US
Practice Address - Phone:989-731-2140
Practice Address - Fax:989-731-2205
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063467207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F960010OtherBLUE CROSS
MI103452020Medicaid
MI110233602OtherRAILROAD MEDICARE
MI0M72150007Medicare ID - Type Unspecified
MI103452020Medicaid