Basic Information
| Provider Information | |||||||||
| NPI: | 1285713123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PECK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 81 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344110 | ||||||||
| FaxNumber: | 8023344113 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344110 | ||||||||
| FaxNumber: | 8023344113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 0420006021 | VT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0572880001 | 01 | VT | DME | OTHER | 15842 | 01 | VT | MVP | OTHER | 8000226 | 01 | VT | LADIES FIRST | OTHER | 00005263 | 01 | VT | BLUE SHIELD OF VERMONT | OTHER | 0005263 | 05 | VT | MEDICAID | 99005263 | 05 | NH | MEDICAID |