Basic Information
Provider Information
NPI: 1962445205
EntityType: 2
ReplacementNPI:  
OrganizationName: GREENFIELD COUNTRY MEDICINE
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 3100 ROUTE 9N
Address2: P.O.BOX 159
City: GREENFIELD CENTER
State: NY
PostalCode: 128331711
CountryCode: US
TelephoneNumber: 5182680615
FaxNumber: 5183481279
Practice Location
Address1: 3100 ROUTE 9N
Address2:  
City: GREENFIELD CENTER
State: NY
PostalCode: 128331711
CountryCode: US
TelephoneNumber: 5182680615
FaxNumber: 5183481279
Other Information
ProviderEnumerationDate: 06/14/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PEACOCK BIRSETT
AuthorizedOfficialFirstName: JAMA
AuthorizedOfficialMiddleName: LORYNN
AuthorizedOfficialTitleorPosition: M.D./OWNER
AuthorizedOfficialTelephone: 5182580615
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X239931NYY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
23993101NYNYS LICENSEOTHER
BP977030301NYDEAOTHER


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