Provider Demographics
NPI:1770618183
Name:PEACOCK FOOT CLINIC PC
Entity type:Organization
Organization Name:PEACOCK FOOT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:KING
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-642-7768
Mailing Address - Street 1:325 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-3601
Mailing Address - Country:US
Mailing Address - Phone:910-642-7768
Mailing Address - Fax:910-642-6541
Practice Address - Street 1:325 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3601
Practice Address - Country:US
Practice Address - Phone:910-642-7768
Practice Address - Fax:910-642-6541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC382213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08003OtherBCBS NC
NC8908003Medicaid
NCP00060043OtherRR MEDICARE
NC08003OtherBCBS NC
NCP00060043OtherRR MEDICARE
NC6082380001Medicare NSC