Provider Demographics
NPI:1558770503
Name:MEDPEACH CONSULTING, LLC
Entity Type:Organization
Organization Name:MEDPEACH CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:ENN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:863-232-5062
Mailing Address - Street 1:931 LOWER FAYETTEVILLE RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-5790
Mailing Address - Country:US
Mailing Address - Phone:770-683-4772
Mailing Address - Fax:888-235-9876
Practice Address - Street 1:931 LOWER FAYETTEVILLE RD
Practice Address - Street 2:SUITE J
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5790
Practice Address - Country:US
Practice Address - Phone:770-683-4772
Practice Address - Fax:888-235-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOS8157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA893020594AMedicaid
58945ZMedicare PIN
GA893020594AMedicaid