MEDICARE: LAUREL EVALUATIONS

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	173000000X	Legal Medicine		NJ

General Provider Information

NPI Number	:	1346361128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAUREL EVALUATIONS

Provider Business Mailing Address
First Line	:	523 FELLOWSHIP RD
Second Line	:	SUITE 275
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-3414
Country	:	US
Telephone Number	:	856-235-7666
Fax Number	:	856-222-0427

Provider Business Practice Location Address
First Line	:	523 FELLOWSHIP RD
Second Line	:	SUITE 275
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-3414
Country	:	US
Telephone Number	:	856-235-7666
Fax Number	:	856-222-0427

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH CHARLES PEACOCK
Credential	:	M.D.
Telephone Number	:	856-235-7666

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	06/11/2008

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