1578548558 NPI number — JAMES EDWARD PEACOCK JR. MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578548558 NPI number — JAMES EDWARD PEACOCK JR. MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PEACOCK

Provider First Name:

JAMES

Provider Middle Name:

EDWARD

Provider Name Prefix Text:

Provider Name Suffix Text:

JR.

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1578548558

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/18/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 344

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

WINSTON SALEM

Provider Business Mailing Address State Name:

NC

Provider Business Mailing Address Postal Code:

27102-0344

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

336-716-2255

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

MEDICAL CENTER BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WINSTON SALEM

Provider Business Practice Location Address State Name:

NC

Provider Business Practice Location Address Postal Code:

27157-0001

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

336-716-2255

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

12/13/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  23418 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RI0200X , with the licence number: 23418 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 5282136 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: Q23418 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: 1811158439 . This is a "VIRGINIA MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 440003755 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: NC1806 . This is a "SC MEDICAID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 66361 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
• Identifier: 29170 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".
• Identifier: 6000286000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
• Identifier: 1811158439 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 6026583 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 8966361 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 3699 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".