Basic Information
| Provider Information | |||||||||
| NPI: | 1679686661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEACOCK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704953396 | ||||||||
| FaxNumber: | 7704952307 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 MILSTEAD RD NE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707609949 | ||||||||
| FaxNumber: | 7707609951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 200400941 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 064241 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0000X | 2004-00941 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
| ID | Type | State | Issuer | Description | Q0094F | 05 | SC | MEDICAID | 3810009045 | 05 | WV | MEDICAID | 119857791A | 05 | GA | MEDICAID | 5905021 | 05 | NC | MEDICAID | 7119766 | 01 | NC | AETNA | OTHER | 808364 | 01 | NC | PARTNERS | OTHER | 145JC | 01 | NC | BCBS | OTHER | 1679686661 | 05 | VA | MEDICAID | 199212 | 01 | NC | MEDCOST | OTHER |