Provider Demographics
NPI:1962445205
Name:GREENFIELD COUNTRY MEDICINE
Entity Type:Organization
Organization Name:GREENFIELD COUNTRY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMA
Authorized Official - Middle Name:LORYNN
Authorized Official - Last Name:PEACOCK BIRSETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-258-0615
Mailing Address - Street 1:3100 ROUTE 9N
Mailing Address - Street 2:P.O.BOX 159
Mailing Address - City:GREENFIELD CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:12833-1711
Mailing Address - Country:US
Mailing Address - Phone:518-268-0615
Mailing Address - Fax:518-348-1279
Practice Address - Street 1:3100 ROUTE 9N
Practice Address - Street 2:
Practice Address - City:GREENFIELD CENTER
Practice Address - State:NY
Practice Address - Zip Code:12833-1711
Practice Address - Country:US
Practice Address - Phone:518-268-0615
Practice Address - Fax:518-348-1279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2023-03-07
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
NY239931OtherNYS LICENSE
NYBP9770303OtherDEA