=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720008154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WASHINGTON WOMENS CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 10/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1204 BROWN ST
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27889-4671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-946-6544
-----------------------------------------------------
Fax | 252-975-6540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1204 BROWN ST
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27889-4671
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-946-6544
-----------------------------------------------------
Fax | 252-975-6540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT
-----------------------------------------------------
Name | BRENDA S PEACOCK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 252-946-6544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 33756
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 32556
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------