Healthcare Provider Details

I. General information

NPI: 1811158439
Provider Name (Legal Business Name): JEFFREY EDWARD PEACOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 03/07/2023
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MILLER ST STE I
WINSTON SALEM NC
27104-4206
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-277-2225
  • Fax: 336-227-2231
Mailing address:
  • Phone: 336-277-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2012-00459
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2012-00459
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number2012-00459
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2012-00459
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: