Provider Demographics
NPI:1295155786
Name:PEYSHA, JILL K
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:K
Last Name:PEYSHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E. MARSHALL ST
Mailing Address - Street 2:BOX 980135
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298
Mailing Address - Country:US
Mailing Address - Phone:804-828-7391
Mailing Address - Fax:804-828-0191
Practice Address - Street 1:5105 SOM CENTER RD #107
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-953-5712
Practice Address - Fax:440-953-5713
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101269063208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35.146110OtherOHIO ELICENSE