Provider Demographics
NPI:1699543892
Name:PEASAH, MARVIN
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:PEASAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 NATHANS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-9815
Mailing Address - Country:US
Mailing Address - Phone:336-807-2335
Mailing Address - Fax:
Practice Address - Street 1:3703 NATHANS WAY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-9815
Practice Address - Country:US
Practice Address - Phone:336-807-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care