MEDICARE: DARRYL W. 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	284300000X	Special Hospital	012182R	LA

General Provider Information

NPI Number	:	1487949657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DARRYL W. PETERSON

Provider Business Mailing Address
First Line	:	7855 HOWELL BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70807
Country	:	US
Telephone Number	:	225-454-6000
Fax Number	:	225-454-6016

Provider Business Practice Location Address
First Line	:	7855 HOWELL PLACE BLVD
Second Line	:	SUITE 200
City	:	BATON ROUGE
State	:	LA
Zip	:	70807-5256
Country	:	US
Telephone Number	:	225-454-6000
Fax Number	:	225-454-2603

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DARRYL WAYNE PETERSON
Credential	:	M.D.
Telephone Number	:	225-454-6000

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	06/15/2011

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