Basic Information
Provider Information | |||||||||
NPI: | 1891702171 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEYTON | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 AFFLINK PL STE 100 | ||||||||
Address2: |   | ||||||||
City: | TUSCALOOSA | ||||||||
State: | AL | ||||||||
PostalCode: | 354062289 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2053669740 | ||||||||
FaxNumber: | 2053449992 | ||||||||
Practice Location | |||||||||
Address1: | 1411 W BADDOUR PKWY | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | TN | ||||||||
PostalCode: | 370872513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6154436006 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 2085R0001X | TN11822 | TN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 4021808 | 01 | TN | BC | OTHER | 3037412 | 05 | TN |   | MEDICAID |