Basic Information
Provider Information | |||||||||
NPI: | 1962445205 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREENFIELD COUNTRY MEDICINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 239931 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 239931 | 01 | NY | NYS LICENSE | OTHER | BP9770303 | 01 | NY | DEA | OTHER |