Healthcare Provider Details

I. General information

NPI: 1033536974
Provider Name (Legal Business Name): RAY E PETERS DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

IV. Provider business mailing address

PO BOX 996
HAYDEN ID
83835-0996
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-9422
  • Fax: 573-778-9963
Mailing address:
  • Phone: 208-664-4026
  • Fax: 855-532-5921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberR2C32
License Number StateMO

VIII. Authorized Official

Name: SANDY SCHRACK
Title or Position: CREDENTIALING
Credential:
Phone: 208-664-4026