Provider Demographics
NPI:1134236078
Name:PEACOCK-BETTENDORF, LLC
Entity type:Organization
Organization Name:PEACOCK-BETTENDORF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:PEACOCK
Authorized Official - Last Name:BETTENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-458-8616
Mailing Address - Street 1:PO BOX 15671
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28408-5671
Mailing Address - Country:US
Mailing Address - Phone:910-251-6755
Mailing Address - Fax:910-458-8619
Practice Address - Street 1:2208 S 17TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7515
Practice Address - Country:US
Practice Address - Phone:910-251-6755
Practice Address - Fax:910-458-8619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94004192081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130AXOtherBLUE CROSS/BLUE SHIELD
NC89130AXMedicaid
NC130AXOtherBLUE CROSS/BLUE SHIELD
NC2349206Medicare ID - Type UnspecifiedPROVIDER/GROUP#