NPIMap

Individual provider Active NPI

Michael Theodore Peterson, D.O.

  • Internal Medicine Physician
  • Tafton, PA
National Provider Identifier
1194768606
Registry record updated May 19, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
OS-007805L Issued in PA
Practice address
132 Manly Rd
Tafton, PA 18464-7829
Phone
(570) 226-2151
Fax
(570) 226-1861
NPI assigned
Jun 13, 2006
Last updated
May 19, 2016By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 19, 2016

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X OS-007805L PA Primary

Addresses

Primary practice location

132 Manly Rd
Tafton, PA 18464-7829

Mailing address

601 Park St
Honesdale, PA 18431-1445
Phone (570) 226-2151

Other identifiers 5

IdentifierTypeStateIssuer
8873OtherPAGEISINGER HEALTH PLAN
02042395OtherNYNY MEDICAL ASSISTANCE
PE744170OtherPAHIGHMARK BLUE SHIELD
0014151170001MedicaidPA
003000OtherPAFIRST PRIORITY HEALTH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20050715000446 PA Practitioner - Internal Medicine 8022044585 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
At Still University of Health Sciences, College of Osteo Med, Kirksville, 1989
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

132 Manly Rd
Tafton, PA 18464-7829
Phone (570) 226-2151

412 Como Rd
Lake Como, PA 18437-1020
Phone (570) 798-2828

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

State licenses

LicenseStateTypeSpecialty
OS-007805LPAMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Wayne Memorial Community Health Centers CurrentSince Dec 28, 2015 Accepting new patients
Wayne Memorial Community Health Centers Internal Medicine CurrentSince Dec 28, 2015 Accepting new patients

Locations

1839 Fair Ave
Honesdale, PA 18431
Phone (570) 251-6500

601 Park St
Honesdale, PA 18431
Phone (570) 253-8100

412 Como Rd
Lake Como, PA 18437
Phone (570) 775-7100

132 Manly Rd
Tafton, PA 18464
Phone (570) 226-2151

Interoperability endpoints

  • Direct secure messaging: michael.peterson@direct.wmchc.hie.keyhie.org

Organizations & group practices 4

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

Hospital & facility affiliations 18

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 18

NPI Registry JSON

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

{
    "created_epoch": "1150156800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1463616000000",
    "number": "1194768606",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "601 PARK ST",
            "city": "HONESDALE",
            "state": "PA",
            "postal_code": "184311445",
            "telephone_number": "570-226-2151",
            "fax_number": "570-226-1861"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "132 MANLY RD",
            "city": "TAFTON",
            "state": "PA",
            "postal_code": "184647829",
            "telephone_number": "570-226-2151",
            "fax_number": "570-226-1861"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "MICHAEL",
        "middle_name": "THEODORE",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-13",
        "last_updated": "2016-05-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "PA",
            "license": "OS-007805L",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GEISINGER HEALTH PLAN",
            "identifier": "8873",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NY MEDICAL ASSISTANCE",
            "identifier": "02042395",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HIGHMARK BLUE SHIELD",
            "identifier": "PE744170",
            "state": "PA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0014151170001",
            "state": "PA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIRST PRIORITY HEALTH",
            "identifier": "003000",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Tafton, PA

Sources for this page

Verify at the official NPI Registry.