Basic Information
Provider Information | |||||||||
NPI: | 1629064092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REEP | ||||||||
FirstName: | PEGGY | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23625 COMMERCE PARK | ||||||||
Address2: | SUITE 204 | ||||||||
City: | BEACHWOOD | ||||||||
State: | OH | ||||||||
PostalCode: | 441225845 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162555700 | ||||||||
FaxNumber: | 8668982159 | ||||||||
Practice Location | |||||||||
Address1: | 725 VIXEN RUN | ||||||||
Address2: |   | ||||||||
City: | GATLINBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 377386344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8654303453 | ||||||||
FaxNumber: | 8668982159 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2005 | ||||||||
LastUpdateDate: | 02/05/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 17306 | OK | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 41949 | TN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 8557050 | 05 | WA |   | MEDICAID | P00225875 | 01 | OK | RAILROAD MEDICARE | OTHER | 1477079 | 05 | LA |   | MEDICAID | 5623606 | 01 | OK | AETNA | OTHER | 200052500A | 05 | OK |   | MEDICAID | 502461641001 | 01 | OK | BCBS-LAWTON | OTHER |