MEDICARE: BRUCE E PETERSON P.T.

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	225100000X	Physical Therapist	PT00002292	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	932823	OTHER	WA	FIRST HEALTH
2	8930118	OTHER	WA	CRIME VICTIMS
3	K465803	OTHER	WA	PACIFIC SOURCE
4	113275	OTHER	WA	KAISER PERMANENTE
5	179681	OTHER	WA	DEPARTMENT OF LABOR & IND
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306844063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE E PETERSON P.T.

Provider Business Mailing Address
First Line	:	625 9TH AVENUE
Second Line	:	SUITE 220
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2544
Country	:	US
Telephone Number	:	360-578-1188
Fax Number	:	360-578-6251

Provider Business Practice Location Address
First Line	:	625 9TH AVENUE
Second Line	:	SUITE 220
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2544
Country	:	US
Telephone Number	:	360-578-1188
Fax Number	:	360-578-6251

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/11/2007

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Directions to “ BRUCE E PETERSON P.T.” Practice Location

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