Rejuvenation Medspa

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

REJUVENATION MEDSPA

Practice address

1400 Johnson Ave Ste 4a
Bridgeport, WV 26330-1063

Phone

(304) 848-9998

Fax

(304) 848-9996

NPI assigned

Jan 17, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Timothy Michael Peasak, DO

Title

Owner/Provider

Phone

(304) 841-1293

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1547683200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1547683200000",
    "number": "1780158287",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1400 JOHNSON AVE STE 4A",
            "city": "BRIDGEPORT",
            "state": "WV",
            "postal_code": "263301063",
            "telephone_number": "304-848-9998",
            "fax_number": "304-848-9996"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 JOHNSON AVE STE 4A",
            "city": "BRIDGEPORT",
            "state": "WV",
            "postal_code": "263301063",
            "telephone_number": "304-848-9998",
            "fax_number": "304-848-9996"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REJUVENATION MEDSPA",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-01-17",
        "last_updated": "2019-01-17",
        "status": "A",
        "authorized_official_last_name": "PEASAK",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER/PROVIDER",
        "authorized_official_telephone_number": "304-841-1293",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WV LICENSE NUMBER",
            "identifier": "1942",
            "state": "WV"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Bridgeport, WV
• Providers in Bridgeport, WV by specialty
• Family Medicine Physician in West Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 17, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.