Charles E Peterson, MD

Primary specialty

Vascular Surgery PhysicianTaxonomy code 2086S0129X

License

01028400A Issued in IN

Practice address

621 Memorial Dr Ste 502
South Bend, IN 46601-1075

Phone

(574) 647-5875

Fax

(574) 647-5878

NPI assigned

Dec 29, 2005

Last updated

Jul 8, 2021By the provider in NPPES

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

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Interoperability endpoints

• Direct secure messaging: cpeterson@mybeacon.cernerdirect.com

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

{
    "created_epoch": "1135814400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1625702400000",
    "number": "1326025495",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "710 N NILES AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171924",
            "telephone_number": "574-647-1610",
            "fax_number": "574-237-6069"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "621 MEMORIAL DR STE 502",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466011075",
            "telephone_number": "574-647-5875",
            "fax_number": "574-647-5878"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "500 Arcade Ave Ste 210",
            "address_purpose": "LOCATION",
            "city": "Elkhart",
            "state": "IN",
            "postal_code": "465142485",
            "country_code": "US",
            "telephone_number": "574-389-5656",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "CHARLES",
        "middle_name": "E",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-12-29",
        "last_updated": "2021-07-08",
        "certification_date": "2021-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2086S0129X",
            "taxonomy_group": "",
            "desc": "Surgery, Vascular Surgery",
            "state": "IN",
            "license": "01028400A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "cpeterson@mybeacon.cernerdirect.com",
            "affiliation": "N",
            "address_1": "621 Memorial Dr Ste 502",
            "city": "South Bend",
            "state": "IN",
            "country_code": "US",
            "postal_code": "466011075",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Mathew Peters, LCSW
• Shianne Peters
• John Anthony Petersen, PSY.D.
• Sarah Petersen
• Faye Peterson-Pottinger, LCSW
• Michelle Nicole Peterson, RDN
• Shotunus Denean Peterson, M.S.W
• Tim Peterson, MA
• Gregory J Pettaway II, MD
• Michael Pfeiffer, D.O.

• Vascular Surgery Physician in South Bend, IN
• Providers in South Bend, IN by specialty
• Vascular Surgery Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2021; 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.