Provider Demographics
NPI:1154419364
Name:PAUL E PEACH MD PC
Entity type:Organization
Organization Name:PAUL E PEACH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:SPELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-446-8960
Mailing Address - Street 1:810 13TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1333
Mailing Address - Country:US
Mailing Address - Phone:229-446-8960
Mailing Address - Fax:229-439-8861
Practice Address - Street 1:810 13TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1333
Practice Address - Country:US
Practice Address - Phone:229-446-8960
Practice Address - Fax:229-439-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028623208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5175Medicare ID - Type Unspecified