Provider Demographics
NPI:1396875746
Name:JANA PETERS
Entity type:Organization
Organization Name:JANA PETERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-425-3922
Mailing Address - Street 1:365 COURTHOUSE ROAD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740
Mailing Address - Country:US
Mailing Address - Phone:304-425-3922
Mailing Address - Fax:304-487-0229
Practice Address - Street 1:365 COURTHOUSE ROAD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-425-3922
Practice Address - Fax:304-487-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720758OtherMT STATE BCBS
WV0041701001Medicaid
WV0041701001Medicaid
WV513891Medicare Oscar/Certification