Basic Information
| Provider Information | |||||||||
| NPI: | 1972570331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PECK | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1133 COLLEGE AVE | ||||||||
| Address2: | SUITE E110 | ||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665022770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855372651 | ||||||||
| FaxNumber: | 7855374276 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 COLLEGE AVE | ||||||||
| Address2: | SUITE E110 | ||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665022770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855372651 | ||||||||
| FaxNumber: | 7855374276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0420773 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 068002164 | 01 | KS | MEDICARE PTAN | OTHER | 100175640D | 05 | KS | MEDICAID |