Healthcare Provider Details

I. General information

NPI: 1205493335
Provider Name (Legal Business Name): NICHOLAS PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

PO BOX 788735
PHILADELPHIA PA
19178-8735
US

V. Phone/Fax

Practice location:
  • Phone: 215-457-4444
  • Fax: 215-457-7602
Mailing address:
  • Phone: 215-456-7000
  • Fax: 215-457-7602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberTRN40885
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD490367
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: