Healthcare Provider Details

I. General information

NPI: 1669839833
Provider Name (Legal Business Name): ROBERT PECK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 DOW RD
ORRINGTON ME
04474-3540
US

IV. Provider business mailing address

365 DOW RD
ORRINGTON ME
04474-3540
US

V. Phone/Fax

Practice location:
  • Phone: 207-852-5545
  • Fax:
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 Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA163030
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: