MEDICARE: DR. HEATHER RAE PECK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0900X	Dermatopathology Physician	036139839	IL
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	23465	NE
3	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	40437	IA
4	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	55747	MN
5	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	8411	SD

General Provider Information

NPI Number	:	1063681005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEATHER RAE PECK M.D.

Provider Business Mailing Address
First Line	:	2805 5TH ST STE 210
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-7330
Country	:	US
Telephone Number	:	605-343-2267
Fax Number	:

Provider Business Practice Location Address
First Line	:	2805 5TH ST STE 210
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-7330
Country	:	US
Telephone Number	:	605-343-2267
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2008
Last Update Date	:	07/21/2022

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