MEDICARE: TAMARA PETERSON

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1366853756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA PETERSON

Provider Business Mailing Address
First Line	:	4840 FOREST DR
Second Line	:	SUITE 6-B, #259
City	:	COLUMBIA
State	:	SC
Zip	:	29206-4810
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 CLIVE ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-3021
Country	:	US
Telephone Number	:	803-530-5314
Fax Number	:

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

Provider Enumeration Date	:	05/19/2014
Last Update Date	:	05/19/2014

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Directions to “ TAMARA PETERSON ” Practice Location

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