Wallace Curtis Peterson, MD

Primary specialty

Anesthesiology PhysicianTaxonomy code 207L00000X

License

168281-1205 Issued in UT

Practice address

100 N Medical Dr
Salt Lake City, UT 84113-1103

Phone

(801) 993-9551

Fax

(801) 733-5872

NPI assigned

Aug 25, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 10

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Pediatric Anesthesiologists Inc

  • Anesthesiology Physician
  • Salt Lake City, UT
  • NPI 1417965799
  Medicare reassignment

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

{
    "created_epoch": "1156464000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1164539987",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1954 FORT UNION BLVD",
            "address_2": "#111",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841216800",
            "telephone_number": "801-993-9551"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 N MEDICAL DR",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841131103",
            "telephone_number": "801-993-9551",
            "fax_number": "801-733-5872"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "WALLACE",
        "middle_name": "CURTIS",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-25",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207L00000X",
            "taxonomy_group": "",
            "desc": "Anesthesiology",
            "state": "UT",
            "license": "168281-1205",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ALTIUS",
            "identifier": "QM0000049533",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "IHC",
            "identifier": "107006366101",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHY U",
            "identifier": "2330",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EDUCATORS MUTUAL",
            "identifier": "870280408PE2",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PEHP",
            "identifier": "24409",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MOLINA",
            "identifier": "PR00612",
            "state": "UT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "401765",
            "state": "MT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DESERET MUTUAL",
            "identifier": "416944",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTHCARE",
            "identifier": "2000040",
            "state": "UT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "710287",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Suzanne V Peterson, FNP-C, RN
• Tania Peterson
• Timothy Jordan Peterson
• Tonee Peterson
• Vanessa Peterson
• William Peterson
• Taylor Lee Petery, MD
• Sarah Petherbridge
• Cari R Petlovany
• Geniel Amanda Peto, LCSW

• Anesthesiology Physician in Salt Lake City, UT
• Providers in Salt Lake City, UT by specialty
• Anesthesiology Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.