MEDICARE: PETER IVERSEN

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	2084P0800X	Psychiatry Physician	35.082331	OH

General Provider Information

NPI Number	:	1770660540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER IVERSEN

Provider Business Mailing Address
First Line	:	2611 WAYNE AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45420-1833
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2611 WAYNE AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45420-1833
Country	:	US
Telephone Number	:	937-258-0440
Fax Number	:

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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Directions to “ PETER IVERSEN ” Practice Location

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