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1396740668

NPI Code Detail

MEDICARE: PETER STEVAN JEROME M.D.

MEDICARE: PETER STEVAN JEROME 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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	12731	ND
2	207RP1001X	Pulmonary Disease Physician	51376	MN
3	207RP1001X	Pulmonary Disease Physician	23793	WI
4	207RP1001X	Pulmonary Disease Physician	M-12784	ID
5	207RS0012X	Sleep Medicine (Internal Medicine) Physician	M-12784	ID
6	207RP1001X	Pulmonary Disease Physician	P4321	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00849680	OTHER	MN	RAILROAD MEDICARE
2	P02137176	OTHER	TX	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396740668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER STEVAN JEROME M.D.

Provider Business Mailing Address
First Line	:	1000 1ST DR NW
Second Line	:
City	:	AUSTIN
State	:	MN
Zip	:	55912-2941
Country	:	US
Telephone Number	:	507-433-7351
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 E MARSHALL AVE
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-5580
Country	:	US
Telephone Number	:	903-315-1488
Fax Number	:	903-315-1656

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

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	01/11/2021

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Directions to “ PETER STEVAN JEROME M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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