Basic Information
| Provider Information | |||||||||
| NPI: | 1740419746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAVITT | ||||||||
| OtherFirstName: | PEGGY | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2009 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD48253 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101258407 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1740419746 | 05 | VA | MEDICAID | 1528940 | 05 | TN | MEDICAID | 1740419746 | 05 | NC | MEDICAID |