NPIMap

Organization Active NPI

Peter a Koretsky MD PA

  • Gastroenterology Physician
  • Melbourne, FL
National Provider Identifier
1124117791
Registry record updated Mar 28, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gastroenterology PhysicianTaxonomy code 207RG0100X
Legal business name
PETER A KORETSKY MD PA
Practice address
2955 Pineda Plaza Way Ste 115
Melbourne, FL 32940-7306
Phone
(321) 254-7375
Fax
(321) 254-7145
NPI assigned
Oct 12, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 28, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Peter A Koretsky, MDNPI 1467556456
Title
President
Phone
(321) 254-7375

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Gastroenterology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RG0100X Primary

Addresses

Primary practice location

2955 Pineda Plaza Way Ste 115
Melbourne, FL 32940-7306

Mailing address

2955 Pineda Plaza Way Ste 115
Melbourne, FL 32940-7306
Phone (321) 254-7375

Other identifiers 1

IdentifierTypeStateIssuer
2734737MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20051107000293 FL Part B Supplier - Clinic/Group Practice 6406874601 Receives reassigned benefits from 5 practitioners
Practice locations: Melbourne, FL

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2323480Peter a Koretsky MD PA2955 Pineda Plaza Way, Melbourne, FL 32940RegistrationMay 7, 2027

National Provider Directory

National Provider Directory

Locations

2955 Pineda Plaza Way
Ste 115
Melbourne, FL 32940
Phone (321) 254-7375

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160611200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1395964800000",
    "number": "1124117791",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2955 PINEDA PLAZA WAY STE 115",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329407306",
            "telephone_number": "321-254-7375",
            "fax_number": "321-254-7145"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2955 PINEDA PLAZA WAY STE 115",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329407306",
            "telephone_number": "321-254-7375",
            "fax_number": "321-254-7145"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETER A KORETSKY MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-12",
        "last_updated": "2014-03-28",
        "status": "A",
        "authorized_official_last_name": "KORETSKY",
        "authorized_official_first_name": "PETER",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "321-254-7375",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207RG0100X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Gastroenterology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2734737",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Melbourne, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 28, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.