Provider Demographics
NPI:1598006900
Name:PEAVY, STANLEY LAMAR
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:LAMAR
Last Name:PEAVY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11065 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-2927
Mailing Address - Country:US
Mailing Address - Phone:513-386-7801
Mailing Address - Fax:
Practice Address - Street 1:11065 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-2927
Practice Address - Country:US
Practice Address - Phone:513-386-7801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-09
Last Update Date:2013-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service