Healthcare Provider Details

I. General information

NPI: 1144611591
Provider Name (Legal Business Name): EDWIN CADY PECK III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

IV. Provider business mailing address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-5111
  • Fax: 626-397-5111
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA140979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: