Basic Information
| Provider Information | |||||||||
| NPI: | 1356548796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEAT | ||||||||
| FirstName: | AUSTIN | ||||||||
| MiddleName: | ELLERBE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1508 WILLOW LAWN DR | ||||||||
| Address2: | STE 117 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042888327 | ||||||||
| FaxNumber: | 8042823744 | ||||||||
| Practice Location | |||||||||
| Address1: | 1508 WILLOW LAWN DR | ||||||||
| Address2: | STE 117 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232303421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042888327 | ||||||||
| FaxNumber: | 8042823744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101251103 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | 0116019471 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 224564 | 01 | VA | ANTHEM | OTHER | P01200810 | 01 | VA | MEDICARE R/R | OTHER | 1356548796 | 05 | VA | MEDICAID |