Provider Demographics
NPI:1578159372
Name:PEEBLES, BRIAN DORSEY
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DORSEY
Last Name:PEEBLES
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 1:55 OHOOPEE RD
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:GA
Mailing Address - Zip Code:31002-2824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3651 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6521
Practice Address - Country:US
Practice Address - Phone:478-494-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN243365367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty