Provider Demographics
NPI:1265403679
Name:VIALL, PETER H JR (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:H
Last Name:VIALL
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:10850 E TRAVERSE HWY
Mailing Address - Street 2:STE 4400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1364
Mailing Address - Country:US
Mailing Address - Phone:231-346-6930
Mailing Address - Fax:231-346-6017
Practice Address - Street 1:4543 S M 88 HWY
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49615-9109
Practice Address - Country:US
Practice Address - Phone:231-533-8661
Practice Address - Fax:531-533-6028
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-10-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI059450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080B86010OtherBLUE SHIELD
MI3181320Medicaid
MIB86010005Medicare ID - Type Unspecified
MIG06136Medicare UPIN
MI1265403679Medicare PIN