Provider Demographics
NPI:1417263534
Name:GEORGE H PEACOCK MD PC
Entity Type:Organization
Organization Name:GEORGE H PEACOCK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANANGER
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTILLANES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-947-6359
Mailing Address - Street 1:804 E NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9119
Mailing Address - Country:US
Mailing Address - Phone:505-947-6359
Mailing Address - Fax:505-326-2773
Practice Address - Street 1:804 E NAVAJO ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9119
Practice Address - Country:US
Practice Address - Phone:505-947-6359
Practice Address - Fax:505-326-2773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM76-82208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13136Medicaid
NM525826280MMedicare PIN
NM13136Medicaid