Provider Demographics
NPI:1669643078
Name:TIMOTHY M PEASAK DO PLLC
Entity Type:Organization
Organization Name:TIMOTHY M PEASAK DO PLLC
Other - Org Name:ELKINS EXPRESS CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PEASAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-637-0180
Mailing Address - Street 1:1513 HARRISON AVE
Mailing Address - Street 2:STE. 18
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3356
Mailing Address - Country:US
Mailing Address - Phone:304-637-0180
Mailing Address - Fax:304-637-1004
Practice Address - Street 1:1513 HARRISON AVE
Practice Address - Street 2:STE. 18
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3356
Practice Address - Country:US
Practice Address - Phone:304-637-0180
Practice Address - Fax:304-637-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1942207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6683950001Medicare NSC