Provider Demographics
NPI:1215912795
Name:PETERS, NEILL T (MD)
Entity type:Individual
Prefix:MR
First Name:NEILL
Middle Name:T
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2525 S MICHIGAN AVE
Mailing Address - Street 2:B-390
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2333
Mailing Address - Country:US
Mailing Address - Phone:312-567-6691
Mailing Address - Fax:312-328-7895
Practice Address - Street 1:5525 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4417
Practice Address - Country:US
Practice Address - Phone:773-585-1955
Practice Address - Fax:773-284-5268
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095483 / 03Medicaid
IL01621679OtherBCBS OF IL
IL01621679OtherBCBS OF IL
ILG56798Medicare UPIN