Healthcare Provider Details

I. General information

NPI: 1679686661
Provider Name (Legal Business Name): KEVIN H PEACOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MILSTEAD RD NE SUITE 110
CONYERS GA
30012-3838
US

IV. Provider business mailing address

1835 SAVOY DR SUITE 300
ATLANTA GA
30341-1072
US

V. Phone/Fax

Practice location:
  • Phone: 770-760-9949
  • Fax: 770-760-9951
Mailing address:
  • Phone: 770-495-3396
  • Fax: 770-495-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number200400941
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number064241
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2004-00941
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: