Healthcare Provider Details

I. General information

NPI: 1265427306
Provider Name (Legal Business Name): MICHAEL L. PECK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 10/17/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 JOLLY RD
PLYMOUTH MEETING PA
19462-2324
US

IV. Provider business mailing address

3130 GRANDVIEW RD
HANOVER PA
17331-9134
US

V. Phone/Fax

Practice location:
  • Phone: 717-451-5956
  • Fax:
Mailing address:
  • Phone: 717-632-2088
  • Fax: 717-637-9482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberXP1503172
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS006590L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: