Active NPI
Mary Kay Peterson, MD
- Diagnostic Radiology Physician
- Fort Myers, FL
National Provider Identifier
1508805656
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Diagnostic Radiology Physician
- License
- ME77132
- Practice address
- 3680 Broadway
Fort Myers, FL 33901-8005 - Phone
- (239) 936-2316
- NPI assigned
- Jun 5, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Diagnostic Radiology Physician | 2085R0202X | ME77132 | FL | Primary |
Addresses
Primary practice location
3680 Broadway
Fort Myers, FL 33901-8005
Mailing address
3660 Broadway
Fort Myers, FL 33901-8005
Phone (239) 936-2316
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ME77132 | Other | FL | FLORIDA LICENSE |
| 257739900 | Medicaid | FL | |
| 46568 | Other | BCBS | |
| 7405122 | Other | AETNA PPO | |
| 2439859 | Other | AETNA HMO |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Networks
- Freedom Health HMO Network
- Optimum HealthCare HMO Network
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1149465600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1212019200000",
"number": "1508805656",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3660 BROADWAY",
"city": "FORT MYERS",
"state": "FL",
"postal_code": "339018005",
"telephone_number": "239-936-2316"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3680 BROADWAY",
"city": "FORT MYERS",
"state": "FL",
"postal_code": "339018005",
"telephone_number": "239-936-2316"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSON",
"first_name": "MARY KAY",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-06-05",
"last_updated": "2008-05-29",
"status": "A"
},
"taxonomies": [
{
"code": "2085R0202X",
"taxonomy_group": "",
"desc": "Radiology, Diagnostic Radiology",
"state": "FL",
"license": "ME77132",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FLORIDA LICENSE",
"identifier": "ME77132",
"state": "FL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "257739900",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "46568",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA PPO",
"identifier": "7405122",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA HMO",
"identifier": "2439859",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Myers, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2008; 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.