1114027950 NPI number — DR. CAROLINE ANNE PECK M.D.

Table of content: DR. CAROLINE ANNE PECK M.D. (NPI 1114027950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114027950 NPI number — DR. CAROLINE ANNE PECK M.D.

Organization/Personal Information

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

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:
1114027950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 997413
Provider Second Line Business Mailing Address:
MS 7213
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95899-7413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-552-9940
Provider Business Mailing Address Fax Number:
916-552-9994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 CAPITOL AVE
Provider Second Line Business Practice Location Address:
STE 74.3.84
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95814-5052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-552-9940
Provider Business Practice Location Address Fax Number:
916-552-9994
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: 207V00000X , with the licence number:  A056319 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2083P0901X , with the licence number: A056319 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 01789813 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 486896 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65924843 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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