=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669643078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMOTHY M PEASAK DO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2008
-----------------------------------------------------
Last Update Date | 09/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1513 HARRISON AVE STE. 18
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-637-0180
-----------------------------------------------------
Fax | 304-637-1004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1513 HARRISON AVE STE. 18
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-637-0180
-----------------------------------------------------
Fax | 304-637-1004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIMOTHY MICHAEL PEASAK
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 304-637-0180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 1942
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------