Provider Demographics
NPI:1740394105
Name:EASTERN SHORE HEART CENTER
Entity type:Organization
Organization Name:EASTERN SHORE HEART CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN /PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-990-1930
Mailing Address - Street 1:19725 SOUTH GREENO ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-3843
Mailing Address - Country:US
Mailing Address - Phone:251-990-1930
Mailing Address - Fax:251-990-1931
Practice Address - Street 1:19725 SOUTH GREENO ROAD
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3843
Practice Address - Country:US
Practice Address - Phone:251-990-1930
Practice Address - Fax:251-990-1931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALK744Medicare PIN
ALB63471Medicare UPIN