Provider Demographics
NPI:1124077714
Name:GROSSE-PERDEKAMP, MARIA T (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:T
Last Name:GROSSE-PERDEKAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-3466
Practice Address - Street 1:509 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-1645
Practice Address - Country:US
Practice Address - Phone:217-383-6636
Practice Address - Fax:217-383-3466
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110021207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110021Medicaid
IL208905182Medicare PIN
0970490001Medicare NSC
IL036110021Medicaid
ILIL3270602Medicare PIN
K01402Medicare PIN