Provider Demographics
NPI:1538314828
Name:DOC PEACOCKS GREENFIELD COUNTRY MEDICINE, PLLC
Entity Type:Organization
Organization Name:DOC PEACOCKS GREENFIELD COUNTRY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-893-6075
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:12833-0159
Mailing Address - Country:US
Mailing Address - Phone:518-450-9180
Mailing Address - Fax:518-886-1690
Practice Address - Street 1:68 WEST AVE STE 3
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-6044
Practice Address - Country:US
Practice Address - Phone:518-450-9180
Practice Address - Fax:518-886-1690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02804144Medicaid
NYJ100000111Medicare PIN