Provider Demographics
NPI:1770770356
Name:LIN, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LIN
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:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-423-8697
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:700 W FOREST AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3937
Practice Address - Country:US
Practice Address - Phone:731-422-0310
Practice Address - Fax:731-422-0475
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD49088208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529644Medicaid
TN103I245327Medicare PIN