1679686661 NPI number — DR. KEVIN H PEACOCK MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679686661 NPI number — DR. KEVIN H PEACOCK MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PEACOCK

Provider First Name:

KEVIN

Provider Middle Name:

H

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

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:

1679686661

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/09/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1835 SAVOY DR

Provider Second Line Business Mailing Address:

SUITE 300

Provider Business Mailing Address City Name:

ATLANTA

Provider Business Mailing Address State Name:

GA

Provider Business Mailing Address Postal Code:

30341-1072

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

770-495-3396

Provider Business Mailing Address Fax Number:

770-495-2307

Provider First Line Business Practice Location Address:

1501 MILSTEAD RD NE

Provider Second Line Business Practice Location Address:

SUITE 110

Provider Business Practice Location Address City Name:

CONYERS

Provider Business Practice Location Address State Name:

GA

Provider Business Practice Location Address Postal Code:

30012-3838

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

770-760-9949

Provider Business Practice Location Address Fax Number:

770-760-9951

Provider Enumeration Date:

08/16/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RX0202X , with the licence number:  200400941 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RH0003X , with the licence number: 064241 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207RH0000X , with the licence number: 2004-00941 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: Q0094F , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: 3810009045 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
• Identifier: 119857791A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 5905021 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 7119766 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 808364 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 145JC . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 1679686661 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 199212 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".