Provider Demographics
NPI:1649541301
Name:PEINE, KEVIN JEROME (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JEROME
Last Name:PEINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:
Practice Address - Street 1:6644 E BAYWOOD AVE
Practice Address - Street 2:BANNER BAYWOOD MEDICAL CENTER
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-321-3900
Practice Address - Fax:480-321-3840
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46381207R00000X, 208M00000X
NMMD2017-0635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34150757Medicaid
AZ721556Medicaid
AZZ90038Medicare PIN