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General NPI Number Information
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NPI Number | 1396740668
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Entity Type | Individual
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Provider Name | PETER STEVAN JEROME M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/14/2005
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Last Update Date | 01/11/2021
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Provider Practice Location Address
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Address Line | 700 E MARSHALL AVE
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City | LONGVIEW
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State | TX
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Zip | 75601-5580
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Country | US
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Telephone | 903-315-1488
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Fax | 903-315-1656
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Provider Business Mailing Address
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Address Line | 1000 1ST DR NW
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City | AUSTIN
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State | MN
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Zip | 55912-2941
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Country | US
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Telephone | 507-433-7351
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 12731
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 51376
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 23793
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | M-12784
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License Number State | ID
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Taxonomy #5
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Taxonomy Code | 207RS0012X
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Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
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License Number | M-12784
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License Number State | ID
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Taxonomy #6
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | P4321
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License Number State | TX
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