MEDICARE: ERIK PETERSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	174771	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	174771-6W	OTHER	NY	WORKER'S COMPENSATION

General Provider Information

NPI Number	:	1033146410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIK PETERSON D.O.

Provider Business Mailing Address
First Line	:	156 WEST AVE
Second Line	:	EMERGENCY DEPARTMENT
City	:	BROCKPORT
State	:	NY
Zip	:	14420-1229
Country	:	US
Telephone Number	:	585-395-6095
Fax Number	:	585-395-6017

Provider Business Practice Location Address
First Line	:	156 WEST AVE
Second Line	:	EMERGENCY DEPARTMENT
City	:	BROCKPORT
State	:	NY
Zip	:	14420-1229
Country	:	US
Telephone Number	:	585-395-6095
Fax Number	:	585-395-6017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	01/05/2023

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