MEDICARE: TIMOTHY A PETERS M.D.

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	207R00000X	Internal Medicine Physician	01043381	IN
2	207Q00000X	Family Medicine Physician	01043381	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000659776	OTHER	IN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	000000216162	OTHER	IN	BCBS

General Provider Information

NPI Number	:	1285662171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY A PETERS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 6309
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46660-6309
Country	:	US
Telephone Number	:	574-335-8700
Fax Number	:	574-335-0760

Provider Business Practice Location Address
First Line	:	1919 LAKE AVE
Second Line	:	SUITE 104
City	:	PLYMOUTH
State	:	IN
Zip	:	46563-7830
Country	:	US
Telephone Number	:	574-941-2929
Fax Number	:	574-941-3008

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	05/08/2015

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Directions to “ TIMOTHY A PETERS M.D.” Practice Location

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