Provider Demographics
NPI:1629064092
Name:REEP, PEGGY JO (MD)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:JO
Last Name:REEP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23625 COMMERCE PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:216-255-5700
Mailing Address - Fax:866-898-2159
Practice Address - Street 1:725 VIXEN RUN
Practice Address - Street 2:
Practice Address - City:GATLINBURG
Practice Address - State:TN
Practice Address - Zip Code:37738-6344
Practice Address - Country:US
Practice Address - Phone:865-430-3453
Practice Address - Fax:866-898-2159
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK173062085R0202X
TN419492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8557050Medicaid
OKP00225875OtherRAILROAD MEDICARE
LA1477079Medicaid
OK5623606OtherAETNA
OK200052500AMedicaid
OK502461641001OtherBCBS-LAWTON
OKP00225875OtherRAILROAD MEDICARE
WA8557050Medicaid
OK243514000Medicare PIN