Healthcare Provider Details

I. General information

NPI: 1902102502
Provider Name (Legal Business Name): PETER ROGER DEVERSA MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 WALNUT ST
CHATTANOOGA TN
37402-1916
US

IV. Provider business mailing address

979 E 3RD ST SUITE B-1001
CHATTANOOGA TN
37403-2136
US

V. Phone/Fax

Practice location:
  • Phone: 423-643-2576
  • Fax:
Mailing address:
  • Phone: 423-643-2576
  • Fax: 423-648-4570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER ROGER DEVERSA
Title or Position: SOLE MEMBER
Credential: MD
Phone: 423-802-0607