MEDICARE: PEACOCK FOOT CLINIC PC

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	213ES0131X	Foot Surgery Podiatrist	382	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00060043	OTHER	NC	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08003	OTHER	NC	BCBS NC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770618183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACOCK FOOT CLINIC PC

Provider Business Mailing Address
First Line	:	325 JEFFERSON ST
Second Line	:
City	:	WHITEVILLE
State	:	NC
Zip	:	28472-3601
Country	:	US
Telephone Number	:	910-642-7768
Fax Number	:	910-642-6541

Provider Business Practice Location Address
First Line	:	325 JEFFERSON ST
Second Line	:
City	:	WHITEVILLE
State	:	NC
Zip	:	28472-3601
Country	:	US
Telephone Number	:	910-642-7768
Fax Number	:	910-642-6541

Authorized Official
Title or Position	:	SECRETARY TREASURER
Name	:	MRS. SONYA KING PEACOCK
Credential	:
Telephone Number	:	910-642-7768

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	12/12/2019

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Directions to “PEACOCK FOOT CLINIC PC ” Practice Location

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