Provider Demographics
NPI:1265549869
Name:PETERSON, MCKIM C (M D)
Entity type:Individual
Prefix:DR
First Name:MCKIM
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1079
Mailing Address - Street 2:MIDCOAST MEDICINE, PA
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-1079
Mailing Address - Country:US
Mailing Address - Phone:207-236-2169
Mailing Address - Fax:207-230-0413
Practice Address - Street 1:195 UNION ST
Practice Address - Street 2:MIDCOAST MEDICINE, PA
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-6107
Practice Address - Country:US
Practice Address - Phone:207-236-2169
Practice Address - Fax:207-230-0413
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-03-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME013075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME130430000Medicaid
ME130430000Medicaid
MEMM6528Medicare ID - Type Unspecified