NPIMap

Individual provider Active NPI

Marco Antonio Peterson Jr., M.D., M.S.

  • Family Medicine Physician
  • Rochester, MI
National Provider Identifier
1881058709
Registry record updated Oct 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
S3042 Issued in TX
Practice address
1101 W University Dr
2 South
Rochester, MI 48307-1863
Phone
(786) 340-3804
NPI assigned
Apr 6, 2016
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 9, 2022

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 4301500521 MI
Family Medicine Physician 207Q00000X S3042 TX Primary

Addresses

Primary practice location

1101 W University Dr
2 South
Rochester, MI 48307-1863

Mailing address

1910 Roseland Blvd
Tyler, TX 75701-4246
Phone (903) 533-0644

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX
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
I20190927001866 TX Practitioner - Family Practice 1951631365 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2014
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Tyler Internal Medicine Associates, P.aGroup PAC ID 3476541731, 14 clinicians

Practice addresses (Care Compare)

1910 Roseland Blvd
Tyler, TX 75701-4246
Phone (903) 533-0644

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine, Master of Science

State licenses

LicenseStateTypeSpecialty
S3042TXMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Tyler Internal Medicine Associates, P.a. Family Medicine CurrentSince Nov 1, 2022 Accepting new patients
Seniorrounds Medical, LLC Family Medicine CurrentSince Dec 1, 2024 Accepting new patients
Fannin County Hospital Authority Past Accepting new patients

Locations

1910 Roseland Blvd
Tyler, TX 75701
Phone (903) 533-0644

Interoperability endpoints

  • Direct secure messaging: marco.peterson@tima.eclinicaldirectplus.com
  • FHIR API: https://fhir4.healow.com/fhir/r4/ADCFBA

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Trucare Living CentersPalestine, TX, CCN 676257 Skilled nursing facility Operational/Managerial Control
Managing Control - Governing Body
Adp of the SNF		 May 1, 2026
May 1, 2026
Apr 1, 2018

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 3

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.

Hospital & facility affiliations 7

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

NPI Registry JSON

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

{
    "created_epoch": "1459900800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1665273600000",
    "number": "1881058709",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1910 ROSELAND BLVD",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757014246",
            "telephone_number": "903-533-0644",
            "fax_number": "903-533-0441"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 W UNIVERSITY DR",
            "address_2": "2 SOUTH",
            "city": "ROCHESTER",
            "state": "MI",
            "postal_code": "483071863",
            "telephone_number": "786-340-3804"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "MARCO",
        "middle_name": "ANTONIO",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "M.D., M.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-04-06",
        "last_updated": "2022-10-09",
        "certification_date": "2022-10-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "4301500521",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "S3042",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rochester, MI

Sources for this page

Verify at the official NPI Registry.