Provider Demographics
NPI:1932102142
Name:AMMINGER, PETER B (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:AMMINGER
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:ST. JUDE CHILDREN'S RESEARCH HOSPITAL
Mailing Address - Street 2:332 N LAUDERDALE ST., MS 0515
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-2794
Mailing Address - Country:US
Mailing Address - Phone:901-495-3006
Mailing Address - Fax:901-495-3842
Practice Address - Street 1:ST. JUDE CHILDREN'S RESEARCH HOSPITAL
Practice Address - Street 2:332 N LAUDERDALE ST., MS 0515
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-2794
Practice Address - Country:US
Practice Address - Phone:901-495-3006
Practice Address - Fax:901-495-3842
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38052208D00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02575175-03Medicaid
IN200509280AMedicaid
MO209028901Medicaid
TN5440422Medicaid
ME422400000Medicaid
LA1471747Medicaid
TX172233201Medicaid
MN216086200Medicaid
AL009947665Medicaid
AR155224001Medicaid
OH2495438Medicaid
KY64093560Medicaid
MS04179761Medicaid
MI104677876Medicaid
OK200076000AMedicaid
NC7614122Medicaid
SCQ38052Medicaid