Healthcare Provider Details

I. General information

NPI: 1003922055
Provider Name (Legal Business Name): PETER GERARD PRYDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S PARK ST 4 TOWER
MADISON WI
53715-1507
US

IV. Provider business mailing address

1008 SPAIGHT ST
MADISON WI
53703-3506
US

V. Phone/Fax

Practice location:
  • Phone: 608-267-6676
  • Fax:
Mailing address:
  • Phone: 608-294-9450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number39817
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: