MEDICARE: GARY QUINTON 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	208000000X	Pediatrics Physician	MD.03817R	LA
2	208000000X	Pediatrics Physician	MD.7555	AL

General Provider Information

NPI Number	:	1184922163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY QUINTON PECK M.D.

Provider Business Mailing Address
First Line	:	1419 DAUPHINE ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70116-1924
Country	:	US
Telephone Number	:	504-949-4939
Fax Number	:	504-944-1946

Provider Business Practice Location Address
First Line	:	1419 DAUPHINE ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70116-1924
Country	:	US
Telephone Number	:	504-949-4939
Fax Number	:	504-944-1946

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

Provider Enumeration Date	:	03/01/2011
Last Update Date	:	03/01/2011

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