Healthcare Provider Details

I. General information

NPI: 1568460061
Provider Name (Legal Business Name): ANDREW CRAIG PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH STREET SE
CEDAR RAPIDS IA
52403-2404
US

IV. Provider business mailing address

PO BOX 3178
CEDAR RAPIDS IA
52406-3178
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-1721
  • Fax: 319-399-2016
Mailing address:
  • Phone: 319-398-1583
  • Fax: 319-399-2085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number28341
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier56483
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBLUE CROSS/BLUE SHIELD
# 2
Identifier3075358
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: