Healthcare Provider Details

I. General information

NPI: 1982685061
Provider Name (Legal Business Name): EDWARD G PESKIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 BELMONT ST DEPARTMENT OF OBSTETRICS & GYNECOLOGY
WORCESTER MA
01605-2903
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-6255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number55189
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: