Provider Demographics
NPI:1295940419
Name:M. TODD PEACOCK, M.D., P.C.
Entity type:Organization
Organization Name:M. TODD PEACOCK, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-374-5774
Mailing Address - Street 1:911 PLAZA AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6785
Mailing Address - Country:US
Mailing Address - Phone:478-374-5774
Mailing Address - Fax:478-374-9112
Practice Address - Street 1:911 PLAZA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6785
Practice Address - Country:US
Practice Address - Phone:478-374-5774
Practice Address - Fax:478-374-9112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4466Medicare ID - Type UnspecifiedMEDICARE GROUP #