Provider Demographics
NPI:1396740668
Name:JEROME, PETER STEVAN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:STEVAN
Last Name:JEROME
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 1:1000 1ST DR NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2941
Mailing Address - Country:US
Mailing Address - Phone:507-433-7351
Mailing Address - Fax:
Practice Address - Street 1:700 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5580
Practice Address - Country:US
Practice Address - Phone:903-315-1488
Practice Address - Fax:903-315-1656
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12731207RC0200X
MN51376207RP1001X
WI23793207RP1001X
IDM-12784207RP1001X, 207RS0012X
TXP4321207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00849680OtherRAILROAD MEDICARE
TXP02137176OtherMEDICARE RAILROAD
TX393948001Medicaid
IAENROLLEDMedicaid
WI31692500Medicaid
MN290000614Medicare PIN