Jack T Peterson Jr., MD

Primary specialty

SpecialistTaxonomy code 174400000X

License

0422259 Issued in KS

Practice address

631 SW Horne St
Ste 400
Topeka, KS 66606-1661

Phone

(785) 234-9000

Fax

(785) 234-9119

NPI assigned

Jun 9, 2005

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 5

Medicare fee-for-service enrollment

Enrolled in KS

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

Specialty

Plastic and Reconstructive Surgery

Education

Baylor College of Medicine, 1983

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: jpeterson191127@ahs.direct-ci.com

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.

• Center for Plastic Surgery, PA

  • Plastic and Reconstructive Surgery Physician
  • Topeka, KS
  • NPI 1457689770
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1118275200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1335225600000",
    "number": "1508860487",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "631 SW HORNE ST",
            "address_2": "STE 400",
            "city": "TOPEKA",
            "state": "KS",
            "postal_code": "666061661",
            "telephone_number": "785-234-9000",
            "fax_number": "785-234-9119"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "631 SW HORNE ST",
            "address_2": "STE 400",
            "city": "TOPEKA",
            "state": "KS",
            "postal_code": "666061661",
            "telephone_number": "785-234-9000",
            "fax_number": "785-234-9119"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "JACK",
        "middle_name": "T",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-06-09",
        "last_updated": "2012-04-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "KS",
            "license": "0422259",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "240007246",
            "state": "KS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "100516",
            "state": "KS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100144860B",
            "state": "KS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIRST GUARD",
            "identifier": "628770",
            "state": "KS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAX ID",
            "identifier": "481191346",
            "state": "KS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Gwendolyn Jean Petersen, LSCSW
• Rachelle Dawn Petersen, LCMFT
• Carrie Beth Peterson, D.D.S.
• Christina Jo Peterson
• Dawn M Peterson, MD
• Kara N Peterson
• Rachel Brooke Peterson, PT, DPT
• Adam V Petesch, CRNA
• Dominic Anthony Petralia, PHARMD
• Douglas Paul Petrie

• Specialist in Topeka, KS
• Providers in Topeka, KS by specialty
• Specialist in Kansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 24, 2012; 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.
• 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.