MEDICARE: COURTNEY SLOCUM PETERSEN PA-C

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	363A00000X	Physician Assistant	004199	GA
2	363A00000X	Physician Assistant	2624	MA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000867701	OTHER		MEDICARE

General Provider Information

NPI Number	:	1730184375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY SLOCUM PETERSEN PA-C

Provider Business Mailing Address
First Line	:	57 E CONCORD ST
Second Line	:	APT 3
City	:	BOSTON
State	:	MA
Zip	:	02118-1996
Country	:	US
Telephone Number	:	770-519-8108
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 WASHINGTON ST # 178
Second Line	:	TUFTS MEDICAL CENTER
City	:	BOSTON
State	:	MA
Zip	:	02111-1526
Country	:	US
Telephone Number	:	617-636-8200
Fax Number	:	617-636-7587

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

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	01/14/2016

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