1124127162 NPI number — DR. STEPHEN L PECK M.D.

Table of content: DR. STEPHEN L PECK M.D. (NPI 1124127162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124127162 NPI number — DR. STEPHEN L PECK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PECK
Provider First Name:
STEPHEN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124127162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 SHAFFER ST
Provider Second Line Business Mailing Address:
SUITE 232
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49048-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-226-5050
Provider Business Mailing Address Fax Number:
269-226-5034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 SHAFFER ST
Provider Second Line Business Practice Location Address:
SUITE 232
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49048-1647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-226-5050
Provider Business Practice Location Address Fax Number:
269-226-5034
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  4301038298 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 4301038298 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 25-31067 . This is a "PHP/IBA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: SP038298 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P54643 . This is a "BCN" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 1394115 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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