MEDICARE: DR. GAYLE PELTZ 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	207Q00000X	Family Medicine Physician	01059777A	IN

General Provider Information

NPI Number	:	1295957108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GAYLE PELTZ M.D.

Provider Business Mailing Address
First Line	:	46 CHESTNUT ST
Second Line	:	2ND FL.
City	:	RUTHERFORD
State	:	NJ
Zip	:	07070-1704
Country	:	US
Telephone Number	:	201-842-0883
Fax Number	:	201-842-0883

Provider Business Practice Location Address
First Line	:	4021 S 700 E STE 300
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2184
Country	:	US
Telephone Number	:	800-643-6822
Fax Number	:

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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