Healthcare Provider Details

I. General information

NPI: 1861645921
Provider Name (Legal Business Name): EVAN R PECK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2008
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 OKEECHOBEE BLVD 14TH FLOOR
WEST PALM BEACH FL
33401-6349
US

IV. Provider business mailing address

525 OKEECHOBEE BLVD 14TH FLOOR
WEST PALM BEACH FL
33401-6349
US

V. Phone/Fax

Practice location:
  • Phone: 561-804-0200
  • Fax: 561-804-0222
Mailing address:
  • Phone: 561-804-0200
  • Fax: 561-804-0222

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 TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number104554
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number52325
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME 106449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: