Healthcare Provider Details

I. General information

NPI: 1770800575
Provider Name (Legal Business Name): PETERSON MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 03/11/2023
Certification Date: 03/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 HILL COUNTRY DR STE 202
KERRVILLE TX
78028-6024
US

IV. Provider business mailing address

PO BOX 26499
BELFAST ME
04915-2015
US

V. Phone/Fax

Practice location:
  • Phone: 830-258-6237
  • Fax: 830-315-1366
Mailing address:
  • Phone: 830-258-7343
  • Fax: 830-258-7678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number550119
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number550119
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number550119
License Number StateTX

VIII. Authorized Official

Name: LISA MEDOVICH
Title or Position: CFO
Credential:
Phone: 830-258-7632