MEDICARE: ROBERT GOODLOE PETERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	23070	NC

General Provider Information

NPI Number	:	1891852638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT GOODLOE PETERSON M.D.

Provider Business Mailing Address
First Line	:	680 PARKWOOD MEDICAL PARK
Second Line	:
City	:	ELKIN
State	:	NC
Zip	:	28621-2487
Country	:	US
Telephone Number	:	336-835-7208
Fax Number	:	336-835-7209

Provider Business Practice Location Address
First Line	:	680 PARKWOOD MEDICAL PARK
Second Line	:
City	:	ELKIN
State	:	NC
Zip	:	28621-2487
Country	:	US
Telephone Number	:	336-835-7208
Fax Number	:	336-835-7209

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	04/09/2013

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